1. U.S. Code
  2. title 42
  3. chapter 7
  4. subchapter XI
  5. part A
  6. § 1320a-7k

Collapse to view only § 1320a-7k. Medicare and Medicaid program integrity provisions

§ 1301. Definitions
(a) When used in this chapter—
(1) The term “State”, except where otherwise provided, includes the District of Columbia and the Commonwealth of Puerto Rico, and when used in subchapters IV, V, VII, XI, XIX, and XXI includes the Virgin Islands and Guam. Such term when used in subchapters III, IX, and XII also includes the Virgin Islands. Such term when used in subchapter V and in part B of this subchapter also includes American Samoa, the Northern Mariana Islands, and the Trust Territory of the Pacific Islands. Such term when used in subchapters XIX and XXI also includes the Northern Mariana Islands and American Samoa. In the case of Puerto Rico, the Virgin Islands, and Guam, subchapters I, X, and XIV, and subchapter XVI (as in effect without regard to the amendment made by section 301 of the Social Security Amendments of 1972) shall continue to apply, and the term “State” when used in such subchapters (but not in subchapter XVI as in effect pursuant to such amendment after December 31, 1973) includes Puerto Rico, the Virgin Islands, and Guam. Such term when used in subchapter XX also includes the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. Such term when used in subchapter IV also includes American Samoa.
(2) The term “United States” when used in a geographical sense means, except where otherwise provided, the States.
(3) The term “person” means an individual, a trust or estate, a partnership, or a corporation.
(4) The term “corporation” includes associations, joint-stock companies, and insurance companies.
(5) The term “shareholder” includes a member in an association, joint-stock company, or insurance company.
(6) The term “Secretary”, except when the context otherwise requires, means the Secretary of Health and Human Services.
(7) The terms “physician” and “medical care” and “hospitalization” include osteopathic practitioners or the services of osteopathic practitioners and hospitals within the scope of their practice as defined by State law.
(8)
(A) The “Federal percentage” for any State (other than Puerto Rico, the Virgin Islands, and Guam) shall be 100 per centum less the State percentage; and the State percentage shall be that percentage which bears the same ratio to 50 per centum as the square of the per capita income of such State bears to the square of the per capita income of the United States; except that the Federal percentage shall in no case be less than 50 per centum or more than 65 per centum.
(B) The Federal percentage for each State (other than Puerto Rico, the Virgin Islands, and Guam) shall be promulgated by the Secretary between October 1 and November 30 of each year, on the basis of the average per capita income of each State and of the United States for the three most recent calendar years for which satisfactory data are available from the Department of Commerce. Such promulgation shall be conclusive for each of the four quarters in the period beginning October 1 next succeeding such promulgation: Provided, That the Secretary shall promulgate such percentages as soon as possible after August 28, 1958, which promulgation shall be conclusive for each of the eleven quarters in the period beginning October 1, 1958, and ending with the close of June 30, 1961.
(C) The term “United States” means (but only for purposes of subparagraphs (A) and (B) of this paragraph) the fifty States and the District of Columbia.
(D) Promulgations made before satisfactory data are available from the Department of Commerce for a full year on the per capita income of Alaska shall prescribe a Federal percentage for Alaska of 50 per centum and, for purposes of such promulgations, Alaska shall not be included as part of the “United States”. Promulgations made thereafter but before per capita income data for Alaska for a full three-year period are available from the Department of Commerce shall be based on satisfactory data available therefrom for Alaska for such one full year or, when such data are available for a two-year period, for such two years.
(9) The term “shared health facility” means any arrangement whereby—
(A) two or more health care practitioners practice their professions at a common physical location;
(B) such practitioners share (i) common waiting areas, examining rooms, treatment rooms, or other space, (ii) the services of supporting staff, or (iii) equipment;
(C) such practitioners have a person (who may himself be a practitioner)—
(i) who is in charge of, controls, manages, or supervises substantial aspects of the arrangement or operation for the delivery of health or medical services at such common physical location, other than the direct furnishing of professional health care services by the practitioners to their patients; or
(ii) who makes available to such practitioners the services of supporting staff who are not employees of such practitioners;
and who is compensated in whole or in part, for the use of such common physical location or support services pertaining thereto, on a basis related to amounts charged or collected for the services rendered or ordered at such location or on any basis clearly unrelated to the value of the services provided by the person; and
(D) at least one of such practitioners received payments on a fee-for-service basis under subchapters XVIII and XIX in an amount exceeding $5,000 for any one month during the preceding 12 months or in an aggregate amount exceeding $40,000 during the preceding 12 months;
except that such term does not include a provider of services (as defined in section 1395x(u) of this title), a health maintenance organization (as defined in section 300e(a) of this title), a hospital cooperative shared services organization meeting the requirements of section 501(e) of the Internal Revenue Code of 1986, or any public entity.
(10) The term “Administration” means the Social Security Administration, except where the context requires otherwise.
(b) The terms “includes” and “including” when used in a definition contained in this chapter shall not be deemed to exclude other things otherwise within the meaning of the term defined.
(c) Whenever under this chapter or any Act of Congress, or under the law of any State, an employer is required or permitted to deduct any amount from the remuneration of an employee and to pay the amount deducted to the United States, a State, or any political subdivision thereof, then for the purposes of this chapter the amount so deducted shall be considered to have been paid to the employee at the time of such deduction.
(d) Nothing in this chapter shall be construed as authorizing any Federal official, agent, or representative, in carrying out any of the provisions of this chapter, to take charge of any child over the objection of either of the parents of such child, or of the person standing in loco parentis to such child.
(Aug. 14, 1935, ch. 531, title XI, § 1101, 49 Stat. 647; Aug. 10, 1939, ch. 666, title VIII, § 801, 53 Stat. 1398; Aug. 10, 1946, ch. 951, title IV, § 401(a), 60 Stat. 986; June 14, 1948, ch. 468, § 2(a), 62 Stat. 438; Aug. 28, 1950, ch. 809, title IV, § 403(a)(1), (2), (b), 64 Stat. 559; Aug. 1, 1956, ch. 836, title III, § 333, 70 Stat. 852; Pub. L. 85–840, title V, §§ 505, 506, Aug. 28, 1958, 72 Stat. 1050, 1051; Pub. L. 86–70, § 32(a), (d), June 25, 1959, 73 Stat. 149; Pub. L. 86–624, § 30(a), (d), July 12, 1960, 74 Stat. 419, 420; Pub. L. 86–778, title V, § 541, Sept. 13, 1960, 74 Stat. 985; Pub. L. 87–543, title I, § 153, July 25, 1962, 76 Stat. 206; Pub. L. 89–97, title I, § 121(c)(1), July 30, 1965, 79 Stat. 352; Pub. L. 92–603, title II, § 272(a), Oct. 30, 1972, 86 Stat. 1451; Pub. L. 93–233, § 18(z–2)(1)(A), Dec. 31, 1973, 87 Stat. 973; Pub. L. 94–273, § 22, Apr. 21, 1976, 90 Stat. 379; Pub. L. 94–566, title I, § 116(a), Oct. 20, 1976, 90 Stat. 2672; Pub. L. 95–142, § 5(c)(2), (l)(2), Oct. 25, 1977, 91 Stat. 1184, 1191; Pub. L. 97–35, title XXI, §§ 2162(a)(1), 2193(c)(2), title XXIII, § 2352(b), Aug. 13, 1981, 95 Stat. 806, 827, 871; Pub. L. 97–248, title I, §§ 136(a), 160(c), Sept. 3, 1982, 96 Stat. 375, 400; Pub. L. 98–369, div. B, title VI, § 2663(e)(1), (j)(1), July 18, 1984, 98 Stat. 1167, 1170; Pub. L. 99–272, title IX, § 9528(a), Apr. 7, 1986, 100 Stat. 219; Pub. L. 99–514, § 2, title XVIII, §§ 1883(c)(1), 1895(c)(6), Oct. 22, 1986, 100 Stat. 2095, 2918, 2936; Pub. L. 100–203, title IX, § 9135(a)(1), (b)(1), Dec. 22, 1987, 101 Stat. 1330–315; Pub. L. 100–485, title VI, § 601(a), Oct. 13, 1988, 102 Stat. 2407; Pub. L. 103–296, title I, § 108(b)(1), Aug. 15, 1994, 108 Stat. 1481; Pub. L. 105–33, title IV, § 4901(b)(1), Aug. 5, 1997, 111 Stat. 570.)

CITE AS: 42 USC 1301

§ 1301–1. Omitted

CITE AS: 42 USC 1301-1

§ 1301a. Omitted

CITE AS: 42 USC 1301a

§ 1302. Rules and regulations; impact analyses of Medicare and Medicaid rules and regulations on small rural hospitals
(a) The Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services, respectively, shall make and publish such rules and regulations, not inconsistent with this chapter, as may be necessary to the efficient administration of the functions with which each is charged under this chapter.
(b)
(1) Whenever the Secretary publishes a general notice of proposed rulemaking for any rule or regulation proposed under subchapter XVIII, subchapter XIX, or part B of this subchapter that may have a significant impact on the operations of a substantial number of small rural hospitals, the Secretary shall prepare and make available for public comment an initial regulatory impact analysis. Such analysis shall describe the impact of the proposed rule or regulation on such hospitals and shall set forth, with respect to small rural hospitals, the matters required under section 603 of title 5 to be set forth with respect to small entities. The initial regulatory impact analysis (or a summary) shall be published in the Federal Register at the time of the publication of general notice of proposed rulemaking for the rule or regulation.
(2) Whenever the Secretary promulgates a final version of a rule or regulation with respect to which an initial regulatory impact analysis is required by paragraph (1), the Secretary shall prepare a final regulatory impact analysis with respect to the final version of such rule or regulation. Such analysis shall set forth, with respect to small rural hospitals, the matters required under section 604 of title 5 to be set forth with respect to small entities. The Secretary shall make copies of the final regulatory impact analysis available to the public and shall publish, in the Federal Register at the time of publication of the final version of the rule or regulation, a statement describing how a member of the public may obtain a copy of such analysis.
(3) If a regulatory flexibility analysis is required by chapter 6 of title 5 for a rule or regulation to which this subsection applies, such analysis shall specifically address the impact of the rule or regulation on small rural hospitals.
(Aug. 14, 1935, ch. 531, title XI, § 1102, 49 Stat. 647; Aug. 28, 1950, ch. 809, title IV, § 403(c), 64 Stat. 559; Pub. L. 98–369, div. B, title VI, § 2663(j)(2)(D)(i), (l)(2), July 18, 1984, 98 Stat. 1170, 1171; Pub. L. 100–203, title IV, § 4402(a), Dec. 22, 1987, 101 Stat. 1330–226.)

CITE AS: 42 USC 1302

§ 1303. Separability

If any provision of this chapter, or the application thereof to any person or circumstance, is held invalid, the remainder of the chapter, and the application of such provision to other persons or circumstances shall not be affected thereby.

(Aug. 14, 1935, ch. 531, title XI, § 1103, 49 Stat. 648.)

CITE AS: 42 USC 1303

§ 1304. Reservation of right to amend or repeal

The right to alter, amend, or repeal any provision of this chapter is hereby reserved to the Congress.

(Aug. 14, 1935, ch. 531, title XI, § 1104, 49 Stat. 648.)

CITE AS: 42 USC 1304

§ 1305. Short title of chapter

This chapter may be cited as the “Social Security Act”.

(Aug. 14, 1935, ch. 531, title XI, § 1105, 49 Stat. 648.)

CITE AS: 42 USC 1305

§ 1306. Disclosure of information in possession of Social Security Administration or Department of Health and Human Services
(a) Disclosure prohibited; exceptions
(1) No disclosure of any return or portion of a return (including information returns and other written statements) filed with the Commissioner of Internal Revenue under title VIII of the Social Security Act or under subchapter E of chapter 1 or subchapter A of chapter 9 of the Internal Revenue Code [of 1939], or under regulations made under authority thereof, which has been transmitted to the head of the applicable agency by the Commissioner of Internal Revenue, or of any file, record, report, or other paper, or any information, obtained at any time by the head of the applicable agency or by any officer or employee of the applicable agency in the course of discharging the duties of the head of the applicable agency under this chapter, and no disclosure of any such file, record, report, or other paper, or information, obtained at any time by any person from the head of the applicable agency or from any officer or employee of the applicable agency, shall be made except as the head of the applicable agency may by regulations prescribe and except as otherwise provided by Federal law. Any person who shall violate any provision of this section shall be deemed guilty of a felony and, upon conviction thereof, shall be punished by a fine not exceeding $10,000 for each occurrence of a violation, or by imprisonment not exceeding 5 years, or both.
(2) For purposes of this subsection and subsection (b), the term “applicable agency” means—
(A) the Social Security Administration, with respect to matter transmitted to or obtained by such Administration or matter disclosed by such Administration, or
(B) the Department of Health and Human Services, with respect to matter transmitted to or obtained by such Department or matter disclosed by such Department.
(b) Requests for information and services
(c) Cost reimbursement
(d) Compliance with requestsNotwithstanding any other provision of this section, in any case in which—
(1) information regarding whether an individual is shown on the records of the Commissioner of Social Security as being alive or deceased is requested from the Commissioner for purposes of epidemiological or similar research which the Commissioner in consultation with the Secretary of Health and Human Services finds may reasonably be expected to contribute to a national health interest, and
(2) the requester agrees to reimburse the Commissioner for providing such information and to comply with limitations on safeguarding and rerelease or redisclosure of such information as may be specified by the Commissioner,
the Commissioner shall comply with such request, except to the extent that compliance with such request would constitute a violation of the terms of any contract entered into under section 405(r) of this title.
(e) Public inspectionNotwithstanding any other provision of this section the Secretary shall make available to each State agency operating a program under subchapter XIX and shall, subject to the limitations contained in subsection (e),1
1 So in original. Probably should be subsection “(f),”.
make available for public inspection in readily accessible form and fashion, the following official reports (not including, however, references to any internal tolerance rules and practices that may be contained therein, internal working papers or other informal memoranda) dealing with the operation of the health programs established by subchapters XVIII and XIX—
(1) individual contractor performance reviews and other formal evaluations of the performance of carriers, intermediaries, and State agencies, including the reports of follow-up reviews;
(2) comparative evaluations of the performance of such contractors, including comparisons of either overall performance or of any particular aspect of contractor operation; and
(3) program validation survey reports and other formal evaluations of the performance of providers of services, including the reports of follow-up reviews, except that such reports shall not identify individual patients, individual health care practitioners, or other individuals.
(f) Opportunity for review
(g) Agreement with Secretary of the TreasuryNotwithstanding any other provision of this section, the Commissioner of Social Security shall enter into an agreement with the Secretary of the Treasury under which—
(1) if the Secretary provides the Commissioner with the information described in section 6103(k)(15) of the Internal Revenue Code of 1986 with respect to any individual, the Commissioner shall indicate to the Secretary as to whether such individual receives disability insurance benefits under section 423 of this title or supplemental security income benefits under subchapter XVI of this chapter (including State supplementary payments of the type referred to in section 1382e(a) of this title or payments of the type described in section 212(a) of Public Law 93–66 [42 U.S.C. 1382 note]);
(2) appropriate safeguards are included to assure that the indication described in paragraph (1) will be used solely for the purpose of determining if tax receivables involving such individual are not eligible for collection pursuant to a qualified tax collection contract by reason of section 6306(d)(3)(E) of the Internal Revenue Code of 1986; and
(3) the Secretary shall pay the Commissioner of Social Security the full costs (including systems and administrative costs) of providing the indication described in paragraph (1).
(Aug. 14, 1935, ch. 531, title XI, § 1106, as added Aug. 10, 1939, ch. 666, title VIII, § 802, 53 Stat. 1398; amended Aug. 28, 1950, ch. 809, title IV, § 403(d), 64 Stat. 559; Pub. L. 85–840, title VII, § 701, Aug. 28, 1958, 72 Stat. 1055; Pub. L. 89–97, title I, § 108(c), title III, § 340, July 30, 1965, 79 Stat. 339, 411; Pub. L. 90–248, title I, § 168, title II, § 241(c)(1), Jan. 2, 1968, 81 Stat. 875, 917; Pub. L. 92–603, title II, § 249C(a), Oct. 30, 1972, 86 Stat. 1428; Pub. L. 93–647, § 101(d), Jan. 4, 1975, 88 Stat. 2360; Pub. L. 97–35, title XXII, § 2207, Aug. 13, 1981, 95 Stat. 838; Pub. L. 98–369, div. B, title VI, § 2663(j)(2)(D)(ii), (l), July 18, 1984, 98 Stat. 1170, 1171; Pub. L. 103–296, title I, § 108(b)(2)–(5), title III, §§ 311(a), 313(a), Aug. 15, 1994, 108 Stat. 1481, 1482, 1525, 1530; Pub. L. 116–260, div. N, title II, § 283(a), div. FF, title I, § 102(a), Dec. 27, 2020, 134 Stat. 1984, 3083.)

CITE AS: 42 USC 1306

§ 1306a. Public access to State disbursement records

No State or any agency or political subdivision thereof shall be deprived of any grant-in-aid or other payment to which it otherwise is or has become entitled pursuant to subchapter I (other than section 303(a)(3) thereof), IV, X, XIV, or XVI (other than section 1383(a)(3) thereof) of this chapter, by reason of the enactment or enforcement by such State of any legislation prescribing any conditions under which public access may be had to records of the disbursement of any such funds or payments within such State, if such legislation prohibits the use of any list or names obtained through such access to such records for commercial or political purposes.

(Oct. 20, 1951, ch. 521, title VI, § 618, 65 Stat. 569; Pub. L. 86–778, title VI, § 603(a), Sept. 13, 1960, 74 Stat. 992; Pub. L. 87–543, title I, § 141(e), July 25, 1962, 76 Stat. 205.)

CITE AS: 42 USC 1306a

§ 1306b. State data exchanges

Whenever the Commissioner of Social Security requests information from a State for the purpose of ascertaining an individual’s eligibility for benefits (or the correct amount of such benefits) under subchapter II or XVI of this chapter, the standards of the Commissioner promulgated pursuant to section 1306 of this title or any other Federal law for the use, safeguarding, and disclosure of information are deemed to meet any standards of the State that would otherwise apply to the disclosure of information by the State to the Commissioner.

(Pub. L. 106–169, title II, § 209, Dec. 14, 1999, 113 Stat. 1842.)

CITE AS: 42 USC 1306b

§ 1306c. Restriction on access to the Death Master File
(a) In general
(b) Certification program
(1) In generalThe Secretary of Commerce shall establish a program—
(A) to certify persons who are eligible to access the information described in subsection (a) contained on the Death Master File, and
(B) to perform periodic and unscheduled audits of certified persons to determine the compliance by such certified persons with the requirements of the program.
(2) CertificationA person shall not be certified under the program established under paragraph (1) unless such person certifies that access to the information described in subsection (a) is appropriate because such person—
(A) has—
(i) a legitimate fraud prevention interest, or
(ii) a legitimate business purpose pursuant to a law, governmental rule, regulation, or fiduciary duty, and
(B) has systems, facilities, and procedures in place to safeguard such information, and experience in maintaining the confidentiality, security, and appropriate use of such information, pursuant to requirements similar to the requirements of section 6103(p)(4) of the Internal Revenue Code of 1986, and
(C) agrees to satisfy the requirements of such section 6103(p)(4) as if such section applied to such person.
(3) Fees
(A) In general
(B) Report
(c) Imposition of penalty
(1) In generalAny person who is certified under the program established under subsection (b), who receives information described in subsection (a), and who during the period of time described in subsection (a)—
(A) discloses such information to any person other than a person who meets the requirements of subparagraphs (A), (B), and (C) of subsection (b)(2),
(B) discloses such information to any person who uses the information for any purpose not listed under subsection (b)(2)(A) or who further discloses the information to a person who does not meet such requirements, or
(C) uses any such information for any purpose not listed under subsection (b)(2)(A),
and any person to whom such information is disclosed who further discloses or uses such information as described in the preceding subparagraphs, shall pay a penalty of $1,000 for each such disclosure or use.
(2) Limitation on penalty
(A) In general
(B) Exception for willful violations
(d) Death Master File
(e) Exemption from Freedom of Information Act requirement with respect to certain records of deceased individuals
(1) In general
(2) Treatment of information
(f) Effective date
(1) In general
(2) FOIA exemption
(Pub. L. 113–67, div. A, title II, § 203, Dec. 26, 2013, 127 Stat. 1177.)

CITE AS: 42 USC 1306c

§ 1307. Penalty for fraud
(a) Whoever, with the intent to defraud any person, shall make or cause to be made any false representation concerning the requirements of this chapter, of chapter 2, 21, or 23 of the Internal Revenue Code of 1986, or of any provision of subtitle F of such Code which corresponds (within the meaning of section 7852(b) of such Code) to a provision contained in subchapter E of chapter 9 of the Internal Revenue Code of 1939, or of any rules or regulations issued thereunder, knowing such representations to be false, shall be deemed guilty of a misdemeanor, and, upon conviction thereof, shall be punished by a fine not exceeding $1,000, or by imprisonment not exceeding one year, or both.
(b) Whoever, with the intent to elicit information as to the social security account number, date of birth, employment, wages, or benefits of any individual (1) falsely represents to the Commissioner of Social Security or the Secretary that he is such individual, or the wife, husband, widow, widower, divorced wife, divorced husband, surviving divorced wife, surviving divorced husband, surviving divorced mother, surviving divorced father, child, or parent of such individual, or the duly authorized agent of such individual, or of the wife, husband, widow, widower, divorced wife, divorced husband, surviving divorced wife, surviving divorced husband, surviving divorced mother, surviving divorced father, child, or parent of such individual, or (2) falsely represents to any person that he is an employee or agent of the United States, shall be deemed guilty of a felony, and, upon conviction thereof, shall be punished by a fine not exceeding $10,000 for each occurrence of a violation, or by imprisonment not exceeding 5 years, or both.
(Aug. 14, 1935, ch. 531, title XI, § 1107, as added Aug. 10, 1939, ch. 666, title VIII, § 802, 53 Stat. 1398; amended Aug. 28, 1950, ch. 809, title IV, § 403(e), (f), 64 Stat. 560; Pub. L. 98–369, div. B, title VI, § 2663(e)(2)(A), (3), (j)(2)(D)(iii), (l)(1), July 18, 1984, 98 Stat. 1168, 1170, 1171; Pub. L. 99–514, § 2, Oct. 22, 1986, 100 Stat. 2095; Pub. L. 103–296, title I, § 108(b)(6), title III, § 313(b), Aug. 15, 1994, 108 Stat. 1482, 1530.)

CITE AS: 42 USC 1307

§ 1308. Additional grants to Puerto Rico, Virgin Islands, Guam, and American Samoa; limitation on total payments
(a) Limitation on total payments to each territory
(1) In general
(2) Certain payments disregarded
(b) Entitlement to matching grant
(1) In generalEach territory shall be entitled to receive from the Secretary for each fiscal year a grant in an amount equal to 75 percent of the amount (if any) by which—
(A) the total expenditures of the territory during the fiscal year under the territory programs funded under parts A and E of subchapter IV, including any amount paid to the State under part A of subchapter IV that is transferred in accordance with section 604(d) of this title and expended under the program to which transferred; exceeds
(B) the sum of—
(i) the amount of the family assistance grant payable to the territory without regard to section 609 of this title; and
(ii) the total amount expended by the territory during fiscal year 1995 pursuant to parts A and F of subchapter IV (as so in effect), other than for child care.
(2) Appropriation
(c) DefinitionsAs used in this section:
(1) Territory
(2) Ceiling amount
(3) Family assistance grant
(4) Mandatory ceiling amountThe term “mandatory ceiling amount” means—
(A) $107,255,000 with respect to Puerto Rico;
(B) $4,686,000 with respect to Guam;
(C) $3,554,000 with respect to the Virgin Islands; and
(D) $1,000,000 with respect to American Samoa.
(5) Total amount expended by the territoryThe term “total amount expended by the territory”—
(A) does not include expenditures during the fiscal year from amounts made available by the Federal Government; and
(B) when used with respect to fiscal year 1995, also does not include—
(i) expenditures during fiscal year 1995 under subsection (g) or (i) of section 602 of this title (as in effect on September 30, 1995); or
(ii) any expenditures during fiscal year 1995 for which the territory (but for this section, as in effect on September 30, 1995) would have received reimbursement from the Federal Government.
(d) Authority to transfer funds to certain programs
(e) Repealed. Pub. L. 105–33, title V, § 5512(c), Aug. 5, 1997, 111 Stat. 619
(f) Total amount certified under subchapter XIXSubject to subsections (g) and (h) and section 1396u–5(e)(1)(B) of this title, the total amount certified by the Secretary under subchapter XIX with respect to a fiscal year for payment to—
(1) Puerto Rico shall not exceed (A) $116,500,000 for fiscal year 1994 and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase in the medical care component of the consumer price index for all urban consumers (as published by the Bureau of Labor Statistics) for the twelve-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000;
(2) the Virgin Islands shall not exceed (A) $3,837,500 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000;
(3) Guam shall not exceed (A) $3,685,000 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000;
(4) Northern Mariana Islands shall not exceed (A) $1,110,000 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000; and
(5) American Samoa shall not exceed (A) $2,140,000 for fiscal year 1994, and (B) for each succeeding fiscal year the amount provided in this paragraph for the preceding fiscal year increased by the percentage increase referred to in paragraph (1)(B), rounded to the nearest $10,000.
(g) Medicaid payments to territories for fiscal year 1998 and thereafter
(1) Fiscal year 1998With respect to fiscal year 1998, the amounts otherwise determined for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa under subsection (f) for such fiscal year shall be increased by the following amounts:
(A) For Puerto Rico, $30,000,000.
(B) For the Virgin Islands, $750,000.
(C) For Guam, $750,000.
(D) For the Northern Mariana Islands, $500,000.
(E) For American Samoa, $500,000.
(2) Fiscal year 1999 and thereafterNotwithstanding subsection (f) and subject to section 18043(a)(2) of this title and paragraphs (3), (5), and (14), with respect to fiscal year 1999 and any fiscal year thereafter, the total amount certified by the Secretary under subchapter XIX for payment to—
(A) Puerto Rico shall not exceed—
(i) except as provided in clause (ii) or (iii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase in the medical care component of the Consumer Price Index for all urban consumers (as published by the Bureau of Labor Statistics) for the 12-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000;
(ii) for each of fiscal years 2020 through 2021, the amount specified in paragraph (6) for each such fiscal year; and
(iii) for fiscal year 2023 and each subsequent fiscal year, the amount specified in paragraph (11) for such fiscal year;
(B) the Virgin Islands shall not exceed—
(i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000;
(ii) for fiscal year 2020, $128,712,500; and
(iii) for fiscal year 2021, $127,937,500;
(C) Guam shall not exceed—
(i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000;
(ii) for fiscal year 2020, $130,875,000; and
(iii) for fiscal year 2021, $129,712,500;
(D) the Northern Mariana Islands shall not exceed—
(i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000;
(ii) for fiscal year 2020, $63,100,000; and
(iii) for fiscal year 2021, $62,325,000; and
(E) American Samoa shall not exceed—
(i) except as provided in clause (ii), the sum of the amount provided in this subsection for the preceding fiscal year increased by the percentage increase referred to in subparagraph (A), rounded to the nearest $10,000;
(ii) for fiscal year 2020, $86,325,000; and
(iii) for fiscal year 2021, $85,550,000.
For fiscal year 2022 (and, in the case of a territory other than Puerto Rico, for each subsequent fiscal year), the total amount certified for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa under subsection (f) and this subsection for the fiscal year shall be determined as if the preceding subparagraphs were applied to each of fiscal years 2020 through 2021 without regard to clause (ii) of each such subparagraph.
(3) Fiscal years 2006 and 2007 for certain insular areasThe amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa for fiscal year 2006 and fiscal year 2007 shall be increased by the following amounts:
(A) For Puerto Rico, $12,000,000 for fiscal year 2006 and $12,000,000 for fiscal year 2007.
(B) For the Virgin Islands, $2,500,000 for fiscal year 2006 and $5,000,000 for fiscal year 2007.
(C) For Guam, $2,500,000 for fiscal year 2006 and $5,000,000 for fiscal year 2007.
(D) For the Northern Mariana Islands, $1,000,000 for fiscal year 2006 and $2,000,000 for fiscal year 2007.
(E) For American Samoa, $2,000,000 for fiscal year 2006 and $4,000,000 for fiscal year 2007.
Such amounts shall not be taken into account in applying paragraph (2) for fiscal year 2007 but shall be taken into account in applying such paragraph for fiscal year 2008 and subsequent fiscal years.
(4) Exclusion of certain expenditures from payment limits
(A) In general
(B) Additional exemption
(5) Additional increase
(A) Subject to subparagraphs (B), (C), (D), (E), and (F), the Secretary shall increase the amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa (after the application of subsection (f) and the preceding paragraphs of this subsection) for the period beginning July 1, 2011, and ending on September 30, 2019, by such amounts that the total additional payments under subchapter XIX to such territories equals $6,300,000,000 for such period. The Secretary shall increase such amounts in proportion to the amounts applicable to such territories under this subsection and subsection (f) on March 30, 2010.
(B) The amount of the increase otherwise provided under subparagraph (A) for Puerto Rico shall be further increased by $295,900,000.
(C) Subject to subparagraphs (D) and (F), for the period beginning January 1, 2018, and ending September 30, 2019—
(i) the amount of the increase otherwise provided under subparagraphs (A) and (B) for Puerto Rico shall be further increased by $3,600,000,000; and
(ii) the amount of the increase otherwise provided under subparagraph (A) for the Virgin Islands shall be further increased by $106,931,000.
(D) For the period described in subparagraph (C), the amount of the increase otherwise provided under subparagraph (A)—
(i) for Puerto Rico shall be further increased by $1,200,000,000 if the Secretary certifies that Puerto Rico has taken reasonable and appropriate steps during such period, in accordance with a timeline established by the Secretary, to—(I) implement methods, satisfactory to the Secretary, for the collection and reporting of reliable data to the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system); and(II) demonstrate progress in establishing a State medicaid fraud control unit described in section 1396b(q) of this title; and
(ii) for the Virgin Islands shall be further increased by $35,644,000 if the Secretary certifies that the Virgin Islands has taken reasonable and appropriate steps during such period, in accordance with a timeline established by the Secretary, to meet the conditions for certification specified in subclauses (I) and (II) of clause (i).
(E) Subject to subparagraph (F), for the period beginning January 1, 2019, and ending September 30, 2019, the amount of the increase otherwise provided under subparagraph (A) for the Northern Mariana Islands shall be further increased by $36,000,000.
(F) Notwithstanding any other provision of subchapter XIX—
(i) during the period in which the additional funds provided under subparagraphs (C), (D), and (E) are available for Puerto Rico, the Virgin Islands, and the Northern Mariana Islands, respectively, with respect to payments from such additional funds for amounts expended by Puerto Rico, the Virgin Islands, and the Northern Mariana Islands under such subchapter, the Secretary shall increase the Federal medical assistance percentage or other rate that would otherwise apply to such payments to 100 percent; and
(ii) for the period beginning January 1, 2019, and ending September 30, 2019, with respect to payments to Guam and American Samoa from the additional funds provided under subparagraph (A), the Secretary shall increase the Federal medical assistance percentage or other rate that would otherwise apply to such payments to 100 percent.
(G) Not later than September 30, 2019, Guam and American Samoa shall each submit a plan to the Secretary outlining the steps each such territory shall take to collect and report reliable data to the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system).
(6) Application to Puerto Rico for fiscal years 2020 through 2021
(A) In generalSubject to subparagraph (B), the amount specified in this paragraph is—
(i) for fiscal year 2020, $2,716,188,000; and
(ii) for fiscal year 2021, $2,809,063,000.
(B) Additional increase for Puerto Rico
(i) In general
(ii) Application to managed careIn certifying whether Puerto Rico has established a reimbursement floor under a directed payment arrangement plan that satisfies the requirements of clause (i)—(I) for fiscal year 2020, the Secretary shall apply such requirements to payments for physician services under a managed care contract entered into or renewed after December 20, 2019, and disregard payments for physician services under any managed care contract that was entered into prior to such date; and(II) for each of fiscal years 2020 through 2021—(aa) the Secretary shall disregard payments made under sub-capitated arrangements for services such as primary care case management; and(bb) if the reimbursement floor for physician services applicable under a managed care contract satisfies the requirements of clause (i) for the fiscal year in which the contract is entered into or renewed, such reimbursement floor shall be deemed to satisfy such requirements for the subsequent fiscal year.
(7) Puerto Rico program integrity requirements
(A) In general
(i) Program Integrity Lead
(ii) PERM requirement
(iii) Contracting reform reportingNot later than 12 months after December 20, 2019, Puerto Rico shall publish a contracting reform plan to combat fraudulent, wasteful, or abusive contracts under Puerto Rico’s Medicaid program under subchapter XIX that includes—(I) metrics for evaluating the success of the plan; and(II) a schedule for publicly releasing status reports on the plan.
(iv) MEQC
(v) Contracting and procurement oversight lead requirement(I) In general(II) DutiesNot later than 60 days after the end of each fiscal quarter (beginning with the first fiscal quarter beginning on or after the date that is 1 year after December 29, 2022), the officer designated pursuant to subclause (I) shall, with respect to each contract described in clause (iii) with an annual value exceeding $150,000 entered into during such quarter, certify to the Secretary either—(aa) that such contract has met the procurement standards identified under any of sections 75.327, 75.328, and 75.329 of title 45, Code of Federal Regulations (or successor regulations); or(bb) that extenuating circumstances (including a lack of multiple entities competing for such contract) prevented the compliance of such contract with such standards.(III) Publication(IV) Review of compliance
(B) FMAP reduction for failure to meet additional requirements
(i) In generalFor each fiscal quarter during the period beginning on January 1, 2020, and ending on September 30, 2021:(I) For every clause under subparagraph (A) with respect to which Puerto Rico does not fully satisfy the requirements described in the clause (including requirements imposed under the terms of a plan described in the clause) in the fiscal quarter, the Federal medical assistance percentage applicable to Puerto Rico under section 1396d(ff) of this title shall be reduced by the number of percentage points determined for the clause and fiscal quarter under subclause (II).(II) The number of percentage points determined under this subclause with respect to a clause under subparagraph (A) and a fiscal quarter shall be the number of percentage points (not to exceed 2.5 percentage points) equal to—(aa) 0.25 percentage points; multiplied by(bb) the total number of consecutive fiscal quarters for which Puerto Rico has not fully satisfied the requirements described in such clause.
(ii) Exception for extenuating circumstances or reasonable progressFor purposes of clause (i), Puerto Rico shall be deemed to have fully satisfied the requirements of a clause under subparagraph (A) (including requirements imposed under the terms of a plan described in the clause) for a fiscal quarter if—(I) the Secretary approves an application from Puerto Rico describing extenuating circumstances that prevented Puerto Rico from fully satisfying the requirements of the clause; or(II) in the case of a requirement imposed under the terms of a plan described in a clause under subparagraph (A), Puerto Rico has made objectively reasonable progress towards satisfying such terms and has submitted a timely request for an exception to the imposition of a penalty to the Secretary.
(8) Program Integrity Lead requirement for the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa
(A) Program Integrity Lead requirement
(B) FMAP reductionFor each fiscal quarter during fiscal year 2021, if the territory fails to satisfy the requirement of subparagraph (A) for the fiscal quarter, the Federal medical assistance percentage applicable to the territory under section 1396d(ff) of this title for such fiscal quarter shall be reduced by the number of percentage points (not to exceed 5 percentage points) equal to—
(i) 0.25 percentage points; multiplied by
(ii) the total number of fiscal quarters during the fiscal year in which the territory failed to satisfy such requirement.
(C) Scope
(9) Annual report
(A) In generalNot later than the date that is 30 days after the end of each fiscal year (beginning with fiscal year 2020 and ending with fiscal year 2021) and for fiscal year 2023 and each subsequent fiscal year (or, in the case of Puerto Rico, and for fiscal year 2023 and each subsequent fiscal year before fiscal year 2028), in the case that a specified territory receives a Medicaid cap increase, or an increase in the Federal medical assistance percentage for such territory under section 1396d(ff) of this title, for such fiscal year, such territory shall submit to the Chair and Ranking Member of the Committee on Energy and Commerce of the House of Representatives and the Chair and Ranking Member of the Committee on Finance of the Senate a report, employing the most up-to-date information available, that describes how such territory has used such Medicaid cap increase, or such increase in the Federal medical assistance percentage, as applicable, to increase access to health care under the State Medicaid plan of such territory under subchapter XIX (or a waiver of such plan). Such report may include—
(i) the extent to which such territory has, with respect to such plan (or waiver)—(I) increased payments to health care providers;(II) increased covered benefits;(III) expanded health care provider networks; or(IV) improved in any other manner the carrying out of such plan (or waiver); and
(ii) any other information as determined necessary by such territory.
(B) DefinitionsIn this paragraph:
(i) Medicaid cap increase
(ii) Specified territory
(10) Additional increase for Puerto Rico for fiscal year 2022
(A) In general
(B) Application to managed careIn certifying whether Puerto Rico has established a reimbursement floor under a directed payment arrangement plan that satisfies the requirements of subparagraph (A) for fiscal year 2022, the Secretary shall—
(i) disregard payments made under sub-capitated arrangements for services such as primary care case management; and
(ii) if the reimbursement floor for physician services applicable under a managed care contract satisfies the requirements of subparagraph (A) for the fiscal year in which the contract is entered into or renewed, such reimbursement floor shall be deemed to satisfy such requirements for the subsequent fiscal year.
(11) Allotment amounts for Puerto Rico for fiscal year 2023 and subsequent fiscal yearsFor purposes of paragraph (2)(A)(iii), subject to paragraphs (12) and (13), the amounts specified in this paragraph are the following:
(A) For fiscal year 2023, $3,275,000,000.
(B) For fiscal year 2024, $3,325,000,000.
(C) For fiscal year 2025, $3,475,000,000.
(D) For fiscal year 2026, $3,645,000,000.
(E) For fiscal year 2027, $3,825,000,000.
(F) For fiscal year 2028, the sum of the amount that would have been provided under this subsection for Puerto Rico for such fiscal year in accordance with clause (i) of paragraph (2)(A) (without regard to clause (iii) of such paragraph) had the amount provided under this subsection for Puerto Rico for each of fiscal years 2020 through 2027 been equal to the following:
(i) For fiscal year 2020, the sum of the amount provided under this subsection for Puerto Rico for fiscal year 2019, increased by the percentage increase in the medical care component of the Consumer Price Index for all urban consumers (as published by the Bureau of Labor Statistics) for the 12-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000.
(ii) For each of fiscal years 2021 through 2027, the sum of the amount provided under this subparagraph for the preceding fiscal year, increased in accordance with the percentage increase described in clause (i), rounded to the nearest $100,000.
(G) For fiscal year 2029 and each subsequent fiscal year, the sum of the amount specified in this paragraph for the preceding fiscal year, increased by the percentage increase in the medical care component of the Consumer Price Index for all urban consumers (as published by the Bureau of Labor Statistics) for the 12-month period ending in March preceding the beginning of the fiscal year, rounded to the nearest $100,000.
In determining the amount specified under subparagraph (F) for fiscal year 2028 or under subparagraph (G) for fiscal year 2029 or a subsequent fiscal year, the Secretary may in no way take into account the amount that was provided under this subsection for Puerto Rico for fiscal year 2022 that was based on the Centers for Medicare & Medicaid Services’ interpretation of the flush language following paragraph (2)(E) (as described in the letters sent by the Centers for Medicare & Medicaid Services to the Director of the Medicaid Program for Puerto Rico dated September 24, 2021, and November 18, 2021, respectively).
(12) Additional increase for Puerto Rico
(A) In general
(B) Application to managed careIn certifying whether Puerto Rico has established a reimbursement floor under a directed payment arrangement plan that satisfies the requirements of subparagraph (A)—
(i) for fiscal year 2023, the Secretary shall apply such requirements to payments for physician services under a managed care contract entered into or renewed after December 29, 2022, and disregard payments for physician services under any managed care contract that was entered into prior to such date; and
(ii) for each subsequent fiscal year through fiscal year 2027—(I) the Secretary shall disregard payments made under subcapitated arrangements for services such as primary care case management; and(II) if the reimbursement floor for physician services applicable under a managed care contract satisfies the requirements of subparagraph (A) for the fiscal year in which the contract is entered into or renewed, such reimbursement floor shall be deemed to satisfy such requirements for the subsequent fiscal year.
(C) Nonapplication of increase in determining allotments for subsequent fiscal years
(13) Further increase for Puerto Rico
(A) In generalFor each of fiscal years 2023 through 2027, the amount specified in paragraph (11) for the fiscal year shall be equal to the amount specified for such fiscal year under such paragraph (increased, if applicable, in accordance with paragraph (12)) and further increased—
(i) in the case of each of fiscal years 2023 through 2025, by $75,000,000 if the Secretary determines that Puerto Rico fully satisfies the requirements described in paragraph (7)(A)(i) for such fiscal year; and
(ii) in the case of each of fiscal years 2026 and 2027, by $75,000,000 if the Secretary determines that Puerto Rico fully satisfies the requirements described in—(I) paragraph (7)(A)(i) for such fiscal year; and(II) paragraph (7)(A)(v) for such fiscal year.
(B) Nonapplication of increase in determining allotments for subsequent fiscal years
(14) Additional increase for the Northern Mariana Islands
(A) In general
(B) Special rulesThe increase described in subparagraph (A)—
(i) shall apply to the total amount certified by the Secretary under subchapter XIX for payment to the Northern Mariana Islands for services attributable to fiscal year 2023 or 2024, notwithstanding that payments for any such services are made by the Northern Mariana Islands in fiscal year 2025; and
(ii) shall be in addition to the amount calculated under paragraph (2) for the Northern Mariana Islands for fiscal years 2023 and 2024 and shall not be taken into account in calculating an amount under paragraph (2) for the Northern Mariana Islands for fiscal year 2025 or a subsequent fiscal year.
(h) Exclusion of medical assistance expenditures for citizens of freely associated states
(i) Data systems improvement payments
(1) In general
(2) Treatment as Medicaid payments
(A) In general
(B) Nonduplication
(3) AllotmentsThe Secretary shall specify an allotment for each eligible territory for payments made under paragraph (1) in a manner such that—
(A) the total amount of payments made under such paragraph for all eligible territories does not exceed $20,000,000; and
(B) each eligible territory receives an equitable allotment of such payments.
(4) No effect on territorial caps
(5) DefinitionsIn this subsection:
(A) Eligible territory
(B) Qualifying data system improvement expenditure
(Aug. 14, 1935, ch. 531, title XI, § 1108, as added Aug. 28, 1950, ch. 809, title III, pt. 6, § 361(g), 64 Stat. 558; amended Aug. 1, 1956, ch. 836, title III, § 351(c), 70 Stat. 855; Pub. L. 85–840, title V, §§ 507, 508, Aug. 28, 1958, 72 Stat. 1051; Pub. L. 86–778, title VI, § 602, Sept. 13, 1960, 74 Stat. 992; Pub. L. 87–31, § 6(a)(1), (2), (b), May 8, 1961, 75 Stat. 78; Pub. L. 87–64, title III, § 303(d), June 30, 1961, 75 Stat. 143; Pub. L. 87–543, title I, § 151, July 25, 1962, 76 Stat. 206; Pub. L. 89–97, title II, § 208(a)(2), title IV, § 408(a), July 30, 1965, 79 Stat. 355, 422; Pub. L. 90–248, title II, § 248(a)(1), Jan. 2, 1968, 81 Stat. 918; Pub. L. 92–603, title II, §§ 271(a), (b), 272(b), Oct. 30, 1972, 86 Stat. 1451; Pub. L. 93–647, § 3(i), Jan. 4, 1975, 88 Stat. 2350; Pub. L. 95–600, title VIII, § 802(b), Nov. 6, 1978, 92 Stat. 2945; Pub. L. 96–272, title II, § 207(c), title III, §§ 305(a), (b), June 17, 1980, 94 Stat. 526, 529, 530; Pub. L. 97–35, title XXI, §§ 2162(b)(1), 2193(c)(1), title XXIII, § 2353(f), Aug. 13, 1981, 95 Stat. 806, 827, 872; Pub. L. 97–248, title I, §§ 136(b), 160(a), Sept. 3, 1982, 96 Stat. 375, 400; Pub. L. 98–369, div. B, title III, § 2365(a), July 18, 1984, 98 Stat. 1108; Pub. L. 100–203, title IV, § 4111(a), Dec. 22, 1987, 101 Stat. 1330–148; Pub. L. 100–485, title II, § 202(c)(2), (3), title VI, §§ 601(b), (c)(2), 602(a), Oct. 13, 1988, 102 Stat. 2378, 2407, 2408; Pub. L. 103–66, title XIII, § 13641(a), Aug. 10, 1993, 107 Stat. 646; Pub. L. 104–193, title I, § 103(b), Aug. 22, 1996, 110 Stat. 2160; Pub. L. 105–33, title IV, § 4726, title V, §§ 5001(b), 5512, Aug. 5, 1997, 111 Stat. 519, 589, 619; Pub. L. 108–40, § 3(b), June 30, 2003, 117 Stat. 836; Pub. L. 108–173, title I, § 103(d)(2), Dec. 8, 2003, 117 Stat. 2159; Pub. L. 109–171, title VI, § 6055, Feb. 8, 2006, 120 Stat. 96; Pub. L. 111–3, title I, § 109, Feb. 4, 2009, 123 Stat. 25; Pub. L. 111–5, div. B, title II, § 2101(c), (d)(1), Feb. 17, 2009, 123 Stat. 449; Pub. L. 111–148, title II, § 2005(a), (b), title X, § 10201(d), Mar. 23, 2010, 124 Stat. 283, 919; Pub. L. 111–152, title I, § 1204(b)(1), (2)(A), Mar. 30, 2010, 124 Stat. 1056; Pub. L. 112–96, title IV, § 4002(h), Feb. 22, 2012, 126 Stat. 195; Pub. L. 115–31, div. M, title I, § 102(a)(5), title II, § 202(a), May 5, 2017, 131 Stat. 800, 804; Pub. L. 115–123, div. B, title III, § 20301(a), (b), title VII, § 50711(f), Feb. 9, 2018, 132 Stat. 118, 119, 244; Pub. L. 116–20, title VIII, § 802(a), June 6, 2019, 133 Stat. 891; Pub. L. 116–94, div. N, title I, § 202(a), (d), Dec. 20, 2019, 133 Stat. 3103, 3108; Pub. L. 116–127, div. F, § 6009, Mar. 18, 2020, 134 Stat. 209; Pub. L. 116–260, div. CC, title II, §§ 208(d), 210(d), Dec. 27, 2020, 134 Stat. 2985, 2991; Pub. L. 117–103, div. P, title II, § 201(b), Mar. 15, 2022, 136 Stat. 802; Pub. L. 117–328, div. FF, title V, § 5101(a), (d)–(f), Dec. 29, 2022, 136 Stat. 5932, 5935–5937; Pub. L. 118–83, div. B, title II, § 211, Sept. 26, 2024, 138 Stat. 1538.)

CITE AS: 42 USC 1308

§ 1309. Amounts disregarded not to be taken into account in determining eligibility of other individuals

Any amount which is disregarded (or set aside for future needs) in determining the eligibility of and amount of the aid or assistance for any individual under a State plan approved under subchapter I, X, XIV, XVI, or XIX,1

1 So in original. The comma probably should not appear.
shall not be taken into consideration in determining the eligibility of and amount of aid or assistance for any other individual under a State plan approved under any other of such subchapters.

(Aug. 14, 1935, ch. 531, title XI, § 1109, as added July 18, 1952, ch. 945, § 7, 66 Stat. 778; amended Pub. L. 87–543, title I, § 141(c), July 25, 1962, 76 Stat. 205; Pub. L. 89–97, title I, § 121(c)(2), July 30, 1965, 79 Stat. 352; Pub. L. 90–248, title II, § 241(c)(2), Jan. 2, 1968, 81 Stat. 917; Pub. L. 104–193, title I, § 108(g)(1), Aug. 22, 1996, 110 Stat. 2168.)

CITE AS: 42 USC 1309

§ 1310. Cooperative research or demonstration projects
(a) In general
(1) There are hereby authorized to be appropriated for the fiscal year ending June 30, 1957, $5,000,000 and for each fiscal year thereafter such sums as the Congress may determine for (A) making grants to States and public and other organizations and agencies for paying part of the cost of research or demonstration projects such as those relating to the prevention and reduction of dependency, or which will aid in effecting coordination of planning between private and public welfare agencies or which will help improve the administration and effectiveness of programs carried on or assisted under this chapter and programs related thereto, and (B) making contracts or jointly financed cooperative arrangements with States and public and other organizations and agencies for the conduct of research or demonstration projects relating to such matters.
(2) No contract or jointly financed cooperative arrangement shall be entered into, and no grant shall be made, under paragraph (1), until the Secretary (or the Commissioner, with respect to any jointly financed cooperative agreement or grant concerning subchapters II or XVI) obtains the advice and recommendations of specialists who are competent to evaluate the proposed projects as to soundness of their design, the possibilities of securing productive results, the adequacy of resources to conduct the proposed research or demonstrations, and their relationship to other similar research or demonstrations already completed or in process.
(3) Grants and payments under contracts or cooperative arrangements under paragraph (1) may be made either in advance or by way of reimbursement, as may be determined by the Secretary (or the Commissioner, with respect to any jointly financed cooperative agreement or grant concerning subchapter II or XVI); and shall be made in such installments and on such conditions as the Secretary (or the Commissioner, as applicable) finds necessary to carry out the purposes of this subsection.
(b) Limitations and costs
(1) The Commissioner is authorized to waive any of the requirements, conditions, or limitations of subchapter XVI (or to waive them only for specified purposes, or to impose additional requirements, conditions, or limitations) to such extent and for such period as the Commissioner finds necessary to carry out one or more experimental, pilot, or demonstration projects which, in the Commissioner’s judgment, are likely to assist in promoting the objectives or facilitate the administration of such subchapter. Any costs for benefits under or administration of any such project (including planning for the project and the review and evaluation of the project and its results), in excess of those that would have been incurred without regard to the project, shall be met by the Commissioner from amounts available to the Commissioner for this purpose from appropriations made to carry out such subchapter. The costs of any such project which is carried out in coordination with one or more related projects under other subchapters of this chapter shall be allocated among the appropriations available for such projects and any Trust Funds involved, in a manner determined by the Commissioner with respect to the old-age, survivors, and disability insurance programs under subchapter II and the supplemental security income program under subchapter XVI, and by the Secretary with respect to other subchapters of this chapter, taking into consideration the programs (or types of benefit) to which the project (or part of a project) is most closely related or which the project (or part of a project) is intended to benefit. If, in order to carry out a project under this subsection, the Commissioner requests a State to make supplementary payments (or the Commissioner makes them pursuant to an agreement under section 1382e of this title) to individuals who are not eligible therefor, or in amounts or under circumstances in which the State does not make such payments, the Commissioner shall reimburse such State for the non-Federal share of such payments from amounts appropriated to carry out subchapter XVI. If, in order to carry out a project under this subsection, the Secretary requests a State to provide medical assistance under its plan approved under subchapter XIX to individuals who are not eligible therefor, or in amounts or under circumstances in which the State does not provide such medical assistance, the Secretary shall reimburse such State for the non-Federal share of such assistance from amounts appropriated to carry out subchapter XVI, which shall be provided by the Commissioner to the Secretary for this purpose.
(2) With respect to the participation of recipients of supplemental security income benefits in experimental, pilot, or demonstration projects under this subsection—
(A) the Commissioner is not authorized to carry out any project that would result in a substantial reduction in any individual’s total income and resources as a result of his or her participation in the project;
(B) the Commissioner may not require any individual to participate in a project; and the Commissioner shall assure (i) that the voluntary participation of individuals in any project is obtained through informed written consent which satisfies the requirements for informed consent established by the Commissioner for use in any experimental, pilot, or demonstration project in which human subjects are at risk, and (ii) that any individual’s voluntary agreement to participate in any project may be revoked by such individual at any time;
(C) the Commissioner shall, to the extent feasible and appropriate, include recipients who are under age 18 as well as adult recipients; and
(D) the Commissioner shall include in the projects carried out under this section such experimental, pilot, or demonstration projects as may be necessary to ascertain the feasibility of treating alcoholics and drug addicts to prevent the onset of irreversible medical conditions which may result in permanent disability, including programs in residential care treatment centers.
(c) Survey of use of payments
(1) In addition to the amount otherwise appropriated in any other law to carry out subsection (a) for fiscal year 2004, up to $8,500,000 is authorized and appropriated and shall be used by the Commissioner of Social Security under this subsection for purposes of conducting a statistically valid survey to determine how payments made to individuals, organizations, and State or local government agencies that are representative payees for benefits paid under subchapter II or XVI are being managed and used on behalf of the beneficiaries for whom such benefits are paid.
(2) Not later than 18 months after March 2, 2004, the Commissioner of Social Security shall submit a report on the survey conducted in accordance with paragraph (1) to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate.
(Aug. 14, 1935, ch. 531, title XI, § 1110, as added

CITE AS: 42 USC 1310

§ 1311. Public assistance payments to legal representatives

For purposes of subchapters I, X, XIV, and XVI, and part A of subchapter IV, payments on behalf of an individual, made to another person who has been judicially appointed, under the law of the State in which such individual resides, as legal representative of such individual for the purpose of receiving and managing such payments (whether or not he is such individual’s legal representative for other purposes), shall be regarded as money payments to such individual.

(Aug. 14, 1935, ch. 531, title XI, § 1111, as added Pub. L. 85–840, title V, § 511(a), Aug. 28, 1958, 72 Stat. 1051; amended Pub. L. 87–543, title I, § 141(d), July 25, 1962, 76 Stat. 205; Pub. L. 90–248, title II, § 241(c)(3), Jan. 2, 1968, 81 Stat. 917.)

CITE AS: 42 USC 1311

§ 1312. Medical care guides and reports for public assistance and medical assistance

In order to assist the States to extend the scope and span, and improve the quality, of medical care and medical services for which payments are made to or on behalf of needy and low-income individuals under this chapter and in order to promote better public understanding about medical care and medical assistance for needy and low-income individuals, the Secretary shall develop and revise from time to time guides or recommended standards as to the level, span, and quality of medical care and medical services for the use of the States in evaluating and improving their public assistance medical care programs and their programs of medical assistance; shall secure periodic reports from the States on items included in, and the quantity of, medical care and medical services for which expenditures under such programs are made; and shall from time to time publish data secured from these reports and other information necessary to carry out the purposes of this section.

(Aug. 14, 1935, ch. 531, title XI, § 1112, as added Pub. L. 86–778, title VII, § 705, Sept. 13, 1960, 74 Stat. 995; amended Pub. L. 89–97, title IV, § 408(c), July 30, 1965, 79 Stat. 422.)

CITE AS: 42 USC 1312

§ 1313. Assistance for United States citizens returned from foreign countries
(a) Authorization; reimbursement; utilization of facilities of public or private agencies and organizations
(1) The Secretary is authorized to provide temporary assistance to citizens of the United States and to dependents of citizens of the United States, if they (A) are identified by the Department of State as having returned, or been brought, from a foreign country to the United States because of the destitution of the citizen of the United States or the illness of such citizen or any of his dependents or because of war, threat of war, invasion, or similar crisis, and (B) are without available resources.
(2) Except in such cases or classes of cases as are set forth in regulations of the Secretary, provision shall be made for reimbursement to the United States by the recipients of the temporary assistance to cover the cost thereof.
(3) The Secretary may provide assistance under paragraph (1) directly or through utilization of the services and facilities of appropriate public or private agencies and organizations, in accordance with agreements providing for payment, in advance or by way of reimbursement, as may be determined by the Secretary, of the cost thereof. Such cost shall be determined by such statistical, sampling, or other method as may be provided in the agreement.
(b) Plans and arrangements for assistance; consultations
(c) “Temporary assistance” defined
(d) Maximum total amount of temporary assistance
(e) Authority of Secretary to accept gifts
(1) The Secretary may accept on behalf of the United States gifts, in cash or in kind, for use in carrying out the program established under this section. Gifts in the form of cash shall be credited to the appropriation account from which this program is funded, in addition to amounts otherwise appropriated, and shall remain available until expended.
(2) Gifts accepted under paragraph (1) shall be available for obligation or other use by the United States only to the extent and in the amounts provided in appropriation Acts.
(Aug. 14, 1935, ch. 531, title XI, § 1113, as added Pub. L. 87–64, title III, § 302, June 30, 1961, 75 Stat. 142; amended Pub. L. 87–543, title I, § 133, July 25, 1962, 76 Stat. 196; Pub. L. 88–347, June 30, 1964, 78 Stat. 236; Pub. L. 90–36, § 2, June 29, 1967, 81 Stat. 94; Pub. L. 90–248, title V, § 503, Jan. 2, 1968, 81 Stat. 934; Pub. L. 91–41, § 4, July 9, 1969, 83 Stat. 45; Pub. L. 92–40, July 1, 1971, 85 Stat. 96; Pub. L. 94–44, §§ 1, 2, June 28, 1975, 89 Stat. 235; Pub. L. 101–382, title I, § 140, Aug. 20, 1990, 104 Stat. 654; Pub. L. 101–508, title V, § 5056(a), Nov. 5, 1990, 104 Stat. 1388–229; Pub. L. 108–11, title I, § 1701, Apr. 16, 2003, 117 Stat. 585; Pub. L. 109–250, § 1(a), July 27, 2006, 120 Stat. 652; Pub. L. 111–127, § 2, Jan. 27, 2010, 124 Stat. 4; Pub. L. 115–57, § 2(a), Sept. 12, 2017, 131 Stat. 1148; Pub. L. 116–148, § 2(a), July 13, 2020, 134 Stat. 661; Pub. L. 117–39, § 2(a), Aug. 31, 2021, 135 Stat. 336.)

CITE AS: 42 USC 1313

§ 1314. Public advisory groups
(a) Advisory Council on Public Welfare; appointment and functions of initial Council
(b) Membership and representation of interests on initial Council
(c) Technical and other assistance for initial Council; availability of data
(d) Termination of initial Council’s existence on submission of report
(e) Succeeding Councils; appointment; functions; membership; representation of interests; assistance and data; termination
(f) Advisory committees; functions; reports by Secretary
(g) Compensation and travel expenses
(h) Exemption from conflict of interest laws of members of Council or advisory committees; exceptions
(1) Any member of the Council or any advisory committee appointed under this chapter, who is not a regular full-time employee of the United States, is hereby exempted, with respect to such appointment, from the operation of sections 203, 205, and 209 of title 18, except as otherwise specified in paragraph (2) of this subsection.
(2) The exemption granted by paragraph (1) shall not extend—
(A) to the receipt or payment of salary in connection with the appointee’s Government service from any source other than the employer of the appointee at the time of his appointment, or
(B) during the period of such appointment, to the prosecution or participation in the prosecution, by any person so appointed, of any claim against the Government involving any matter with which such person, during such period, is or was directly connected by reason of such appointment.
(Aug. 14, 1935, ch. 531, title XI, § 1114, as added Pub. L. 87–543, title I, § 121, July 25, 1962, 76 Stat. 190; amended Pub. L. 90–248, title IV, § 403(e), Jan. 2, 1968, 81 Stat. 932; Pub. L. 98–369, div. B, title VI, § 2663(e)(4), (j)(2)(D)(iv), July 18, 1984, 98 Stat. 1168, 1170; Pub. L. 106–554, § 1(a)(6) [title V, § 522(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–546; Pub. L. 108–173, title IX, § 948(a)(1)(A), Dec. 8, 2003, 117 Stat. 2425.)

CITE AS: 42 USC 1314

§ 1314a. Measurement and reporting of welfare receipt
(a) Congressional policyThe Congress hereby declares that—
(1) it is the policy and responsibility of the Federal Government to reduce the rate at which and the degree to which families depend on income from welfare programs and the duration of welfare receipt, consistent with other essential national goals;
(2) it is the policy of the United States to strengthen families, to ensure that children grow up in families that are economically self-sufficient and that the life prospects of children are improved, and to underscore the responsibility of parents to support their children;
(3) the Federal Government should help welfare recipients as well as individuals at risk of welfare receipt to improve their education and job skills, to obtain child care and other necessary support services, and to take such other steps as may be necessary to assist them to become financially independent; and
(4) it is the purpose of this section to provide the public with generally accepted measures of welfare receipt so that it can track such receipt over time and determine whether progress is being made in reducing the rate at which and, to the extent feasible, the degree to which, families depend on income from welfare programs and the duration of welfare receipt.
(b) Development of welfare indicators and predictorsThe Secretary of Health and Human Services (in this section referred to as the “Secretary”) in consultation with the Secretary of Agriculture shall—
(1) develop—
(A) indicators of the rate at which and, to the extent feasible, the degree to which, families depend on income from welfare programs and the duration of welfare receipt; and
(B) predictors of welfare receipt;
(2) assess the data needed to report annually on the indicators and predictors, including the ability of existing data collection efforts to provide such data and any additional data collection needs; and
(3) not later than 2 years after October 31, 1994, provide an interim report containing conclusions resulting from the development and assessment described in paragraphs (1) and (2), to—
(A) the Committee on Ways and Means of the House of Representatives;
(B) the Committee on Education and Labor of the House of Representatives;
(C) the Committee on Agriculture of the House of Representatives;
(D) the Committee on Commerce of the House of Representatives;
(E) the Committee on Finance of the Senate;
(F) the Committee on Labor and Human Resources of the Senate; and
(G) the Committee on Agriculture, Nutrition, and Forestry of the Senate.
(c) Advisory Board on Welfare Indicators
(1) Establishment
(2) Composition
(3) Vacancies
(4) DutiesDuties of the Board shall include—
(A) providing advice and recommendations to the Secretary on the development of indicators of the rate at which and, to the extent feasible, the degree to which, families depend on income from welfare programs and the duration of welfare receipt; and
(B) providing advice on the development and presentation of annual reports required under subsection (d).
(5) Travel expenses
(6) Detail of Federal employees
(7) Voluntary service
(8) Termination of Board
(d) Annual welfare indicators report
(1) Preparation
(2) Coverage
(3) ContentsEach report shall set forth for each of the means-tested benefit programs described in paragraph (2)—
(A) indicators of—
(i) the rate at which and, to the extent feasible, the degree to which, families depend on income from welfare programs, and
(ii) the duration of welfare receipt;
(B) trends in indicators;
(C) predictors of welfare receipt;
(D) the causes of welfare receipt;
(E) patterns of multiple program receipt;
(F) such other information as the Secretary deems relevant; and
(G) such recommendations for legislation, which shall not include proposals to reduce eligibility levels or impose barriers to program access, as the Secretary may determine to be necessary or desirable to reduce—
(i) the rate at which and the degree to which families depend on income from welfare programs, and
(ii) the duration of welfare receipt.
(4) Submission
(e) Short title
(Pub. L. 103–432, title II, § 232, Oct. 31, 1994, 108 Stat. 4462; Pub. L. 105–200, title IV, § 410(h), July 16, 1998, 112 Stat. 674; Pub. L. 110–234, title IV, § 4002(b)(1)(A), (B), (2)(X), May 22, 2008, 122 Stat. 1095–1097; Pub. L. 110–246, § 4(a), title IV, § 4002(b)(1)(A), (B), (2)(X), June 18, 2008, 122 Stat. 1664, 1857, 1859.)

CITE AS: 42 USC 1314a

§ 1314b. National Advisory Committee on the Sex Trafficking of Children and Youth in the United States
(a) Official designation
(b) Authority
(c) Membership
(1) Composition
(2) Selection
(3) Period of appointment; vacancies
(4) Compensation
(d) Duties
(1) National response
(2) Policies for cooperation
The Committee shall advise the Secretary and the Attorney General on practical and general policies concerning the cooperation of Federal, State, local, and tribal governments, child welfare agencies, social service providers, physical health and mental health providers, victim service providers, State or local courts with responsibility for conducting or supervising proceedings relating to child welfare or social services for children and their families, Federal, State, and local police, juvenile detention centers, and runaway and homeless youth programs, schools, the gaming and entertainment industry, and businesses and organizations that provide services to youth, on responding to sex trafficking, including the development and implementation of—
(A) successful interventions with children and youth who are exposed to conditions that make them vulnerable to, or victims of, sex trafficking; and
(B) recommendations for administrative or legislative changes necessary to use programs, properties, or other resources owned, operated, or funded by the Federal Government to provide safe housing for children and youth who are sex trafficking victims and provide support to entities that provide housing or other assistance to the victims.
(3) Best practices and recommendations for States
(A) In general
(B) Development
(C) Content
The best practices shall be user-friendly, incorporate the most up-to-date technology, and include the following:
(i) Sample training materials, protocols, and screening tools that, to the extent possible, accommodate for regional differences among the States, to prepare individuals who administer social services to identify and serve children and youth who are sex trafficking victims or at-risk of sex trafficking.
(ii) Multidisciplinary strategies to identify victims, manage cases, and improve services for all children and youth who are at risk of sex trafficking, or are sex trafficking victims, in the United States.
(iii) Sample protocols and recommendations based on current States’ efforts, accounting for regional differences between States that provide for effective, cross-system collaboration between Federal, State, local, and tribal governments, child welfare agencies, social service providers, physical health and mental health providers, victim service providers, State or local courts with responsibility for conducting or supervising proceedings relating to child welfare or social services for children and their families, the gaming and entertainment industry, Federal, State, and local police, juvenile detention centers and runaway and homeless youth programs, housing resources that are appropriate for housing child and youth victims of trafficking, schools, and businesses and organizations that provide services to children and youth. These protocols and recommendations should include strategies to identify victims and collect, document, and share data across systems and agencies, and should be designed to help agencies better understand the type of sex trafficking involved, the scope of the problem, the needs of the population to be served, ways to address the demand for trafficked children and youth and increase prosecutions of traffickers and purchasers of children and youth, and the degree of victim interaction with multiple systems.
(iv) Developing the criteria and guidelines necessary for establishing safe residential placements for foster children who have been sex trafficked as well as victims of trafficking identified through interaction with law enforcement.
(v) Developing training guidelines for caregivers that serve children and youth being cared for outside the home.
(D) Informing States of best practices
(E) Report on State implementation
(e) Reports
(1) In general
The Committee shall submit an interim and a final report on the work of the Committee to—
(A) the Secretary;
(B) the Attorney General;
(C) the Committee on Finance of the Senate; and
(D) the Committee on Ways and Means of the House of Representatives.
(2) Reporting dates
(f) Administration
(1) Agency support
(2) Meetings
(A) In general
(B) Accommodation for Committee members unable to attend in person
(3) Subcommittees
(4) Recordkeeping
(g) Termination
(h) Definition
(Aug. 14, 1935, ch. 531, title XI, § 1114A, as added Pub. L. 113–183, title I, § 121, Sept. 29, 2014, 128 Stat. 1931.)

CITE AS: 42 USC 1314b

§ 1315. Demonstration projects
(a) Waiver of State plan requirements; costs regarded as State plan expenditures; availability of appropriationsIn the case of any experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives of subchapter I, X, XIV, XVI, or XIX, or part A or D of subchapter IV, in a State or States—
(1) the Secretary may waive compliance with any of the requirements of section 302, 602, 654, 1202, 1352, 1382, or 1396a of this title, as the case may be, to the extent and for the period he finds necessary to enable such State or States to carry out such project, and
(2)
(A) costs of such project which would not otherwise be included as expenditures under section 303, 655, 1203, 1353, 1383, or 1396b of this title, as the case may be, and which are not included as part of the costs of projects under section 1310 of this title, shall, to the extent and for the period prescribed by the Secretary, be regarded as expenditures under the State plan or plans approved under such subchapter, or for administration of such State plan or plans, as may be appropriate, and
(B) costs of such project which would not otherwise be a permissible use of funds under part A of subchapter IV and which are not included as part of the costs of projects under section 1310 of this title, shall to the extent and for the period prescribed by the Secretary, be regarded as a permissible use of funds under such part.
In addition, not to exceed $4,000,000 of the aggregate amount appropriated for payments to States under such subchapters for any fiscal year beginning after June 30, 1967, shall be available, under such terms and conditions as the Secretary may establish, for payments to States to cover so much of the cost of such projects as is not covered by payments under such subchapters and is not included as part of the cost of projects for purposes of section 1310 of this title.
(b) Child support enforcement programs
(1) In the case of any experimental, pilot, or demonstration project undertaken under subsection (a) to assist in promoting the objectives of part D of subchapter IV, the project—
(A) must be designed to improve the financial well-being of children or otherwise improve the operation of the child support program;
(B) may not permit modifications in the child support program which would have the effect of disadvantaging children in need of support; and
(C) must not result in increased cost to the Federal Government under part A of such subchapter.
(2) An Indian tribe or tribal organization operating a program under section 655(f) of this title shall be considered a State for purposes of authority to conduct an experimental, pilot, or demonstration project under subsection (a) to assist in promoting the objectives of part D of subchapter IV and receiving payments under the second sentence of that subsection. The Secretary may waive compliance with any requirements of section 655(f) of this title or regulations promulgated under that section to the extent and for the period the Secretary finds necessary for an Indian tribe or tribal organization to carry out such project. Costs of the project which would not otherwise be included as expenditures of a program operating under section 655(f) of this title and which are not included as part of the costs of projects under section 1310 of this title, shall, to the extent and for the period prescribed by the Secretary, be regarded as expenditures under a tribal plan or plans approved under such section, or for the administration of such tribal plan or plans, as may be appropriate. An Indian tribe or tribal organization applying for or receiving start-up program development funding pursuant to section 309.16 of title 45, Code of Federal Regulations, shall not be considered to be an Indian tribe or tribal organization operating a program under section 655(f) of this title for purposes of this paragraph.
(c) Demonstration projects to test alternative definitions of unemployment
(1)
(A) The Secretary shall enter into agreements with up to 8 States submitting applications under this subsection for the purpose of conducting demonstration projects in such States to test and evaluate the use, with respect to individuals who received aid under part A of subchapter IV in the preceding month (on the basis of the unemployment of the parent who is the principal earner), of a number greater than 100 for the number of hours per month that such individuals may work and still be considered to be unemployed for purposes of section 607 of this title. If any State submits an application under this subsection for the purpose of conducting a demonstration project to test and evaluate the total elimination of the 100-hour rule, the Secretary shall approve at least one such application.
(B) If any State with an agreement under this subsection so requests, the demonstration project conducted pursuant to such agreement may test and evaluate the complete elimination of the 100-hour rule and of any other durational standard that might be applied in defining unemployment for purposes of determining eligibility under section 607 of this title.
(2) Notwithstanding section 602(a)(1) of this title, a demonstration project conducted under this subsection may be conducted in one or more political subdivisions of the State.
(3) An agreement under this subsection shall be entered into between the Secretary and the State agency designated under section 602(a)(3) of this title. Such agreement shall provide for the payment of aid under the applicable State plan under part A of subchapter IV as though section 607 of this title had been modified to reflect the definition of unemployment used in the demonstration project but shall also provide that such project shall otherwise be carried out in accordance with all of the requirements and conditions of section 607 of this title (and, except as provided in paragraph (2), any related requirements and conditions under part A of subchapter IV).
(4) A demonstration project under this subsection may be commenced any time after September 30, 1990, and shall be conducted for such period of time as the agreement with the Secretary may provide; except that, in no event may a demonstration project under this section be conducted after September 30, 1995.
(5)
(A) Any State with an agreement under this subsection shall evaluate the comparative cost and employment effects of the use of the definition of unemployment in its demonstration project under this section by use of experimental and control groups comprised of a random sample of individuals receiving aid under section 607 of this title and shall furnish the Secretary with such information as the Secretary determines to be necessary to evaluate the results of the project conducted by the State.
(B) The Secretary shall report the results of the demonstration projects conducted under this subsection to the Congress not later than 6 months after all such projects are completed.
(d) Regulations relating to applications for or renewals of demonstration projects
(1) An application or renewal of any experimental, pilot, or demonstration project undertaken under subsection (a) to promote the objectives of subchapter XIX or XXI in a State that would result in an impact on eligibility, enrollment, benefits, cost-sharing, or financing with respect to a State program under subchapter XIX or XXI (in this subsection referred to as a “demonstration project”) shall be considered by the Secretary in accordance with the regulations required to be promulgated under paragraph (2).
(2) Not later than 180 days after March 23, 2010, the Secretary shall promulgate regulations relating to applications for, and renewals of, a demonstration project that provide for—
(A) a process for public notice and comment at the State level, including public hearings, sufficient to ensure a meaningful level of public input;
(B) requirements relating to—
(i) the goals of the program to be implemented or renewed under the demonstration project;
(ii) the expected State and Federal costs and coverage projections of the demonstration project; and
(iii) the specific plans of the State to ensure that the demonstration project will be in compliance with subchapter XIX or XXI;
(C) a process for providing public notice and comment after the application is received by the Secretary, that is sufficient to ensure a meaningful level of public input;
(D) a process for the submission to the Secretary of periodic reports by the State concerning the implementation of the demonstration project; and
(E) a process for the periodic evaluation by the Secretary of the demonstration project.
(3) The Secretary shall annually report to Congress concerning actions taken by the Secretary with respect to applications for demonstration projects under this section.
(e) Extensions of State-wide comprehensive demonstration projects for which waivers granted
(1) The provisions of this subsection shall apply to the extension of any State-wide comprehensive demonstration project (in this subsection referred to as “waiver project”) for which a waiver of compliance with requirements of subchapter XIX is granted under subsection (a).
(2) During the 6-month period ending 1 year before the date the waiver under subsection (a) with respect to a waiver project would otherwise expire, the chief executive officer of the State which is operating the project may submit to the Secretary a written request for an extension, of up to 3 years (5 years, in the case of a waiver described in section 1396n(h)(2) of this title), of the project.
(3) If the Secretary fails to respond to the request within 6 months after the date it is submitted, the request is deemed to have been granted.
(4) If such a request is granted, the deadline for submittal of a final report under the waiver project is deemed to have been extended until the date that is 1 year after the date the waiver project would otherwise have expired.
(5) The Secretary shall release an evaluation of each such project not later than 1 year after the date of receipt of the final report.
(6) Subject to paragraphs (4) and (7), the extension of a waiver project under this subsection shall be on the same terms and conditions (including applicable terms and conditions relating to quality and access of services, budget neutrality, data and reporting requirements, and special population protections) that applied to the project before its extension under this subsection.
(7) If an original condition of approval of a waiver project was that Federal expenditures under the project not exceed the Federal expenditures that would otherwise have been made, the Secretary shall take such steps as may be necessary to ensure that, in the extension of the project under this subsection, such condition continues to be met. In applying the previous sentence, the Secretary shall take into account the Secretary’s best estimate of rates of change in expenditures at the time of the extension.
(f) Application for extension of waiver project; submission; approvalAn application by the chief executive officer of a State for an extension of a waiver project the State is operating under an extension under subsection (e) (in this subsection referred to as the “waiver project”) shall be submitted and approved or disapproved in accordance with the following:
(1) The application for an extension of the waiver project shall be submitted to the Secretary at least 120 days prior to the expiration of the current period of the waiver project.
(2) Not later than 45 days after the date such application is received by the Secretary, the Secretary shall notify the State if the Secretary intends to review the terms and conditions of the waiver project. A failure to provide such notification shall be deemed to be an approval of the application.
(3) Not later than 45 days after the date a notification is made in accordance with paragraph (2), the Secretary shall inform the State of proposed changes in the terms and conditions of the waiver project. A failure to provide such information shall be deemed to be an approval of the application.
(4) During the 30-day period that begins on the date information described in paragraph (3) is provided to a State, the Secretary shall negotiate revised terms and conditions of the waiver project with the State.
(5)
(A) Not later than 120 days after the date an application for an extension of the waiver project is submitted to the Secretary (or such later date agreed to by the chief executive officer of the State), the Secretary shall—
(i) approve the application subject to such modifications in the terms and conditions—(I) as have been agreed to by the Secretary and the State; or(II) in the absence of such agreement, as are determined by the Secretary to be reasonable, consistent with the overall objectives of the waiver project, and not in violation of applicable law; or
(ii) disapprove the application.
(B) A failure by the Secretary to approve or disapprove an application submitted under this subsection in accordance with the requirements of subparagraph (A) shall be deemed to be an approval of the application subject to such modifications in the terms and conditions as have been agreed to (if any) by the Secretary and the State.
(6) An approval of an application for an extension of a waiver project under this subsection shall be for a period not to exceed 3 years (5 years, in the case of a waiver described in section 1396n(h)(2) of this title).
(7) An extension of a waiver project under this subsection shall be subject to the final reporting and evaluation requirements of paragraphs (4) and (5) of subsection (e) (taking into account the extension under this subsection with respect to any timing requirements imposed under those paragraphs).
(Aug. 14, 1935, ch. 531, title XI, § 1115, as added Pub. L. 87–543, title I, § 122, July 25, 1962, 76 Stat. 192; amended Pub. L. 89–97, title I, § 121(c)(3), July 30, 1965, 79 Stat. 352; Pub. L. 90–36, § 2, June 29, 1967, 81 Stat. 94; Pub. L. 90–248, title II, §§ 241(c)(4), 247, Jan. 2, 1968, 81 Stat. 917, 918; Pub. L. 93–233, § 18(z–2)(1)(B), Dec. 31, 1973, 87 Stat. 973; Pub. L. 93–647, § 3(c), Jan. 4, 1975, 88 Stat. 2349; Pub. L. 95–216, title IV, § 404, Dec. 20, 1977, 91 Stat. 1562; Pub. L. 97–35, title XXIII, § 2353(g), Aug. 13, 1981, 95 Stat. 872; Pub. L. 98–369, div. B, title VI, § 2663(e)(5), July 18, 1984, 98 Stat. 1168; Pub. L. 98–378, § 10, Aug. 16, 1984, 98 Stat. 1317; Pub. L. 99–272, title XIV, § 14001(b)(2), Apr. 7, 1986, 100 Stat. 328; Pub. L. 100–485, title V, § 503, Oct. 13, 1988, 102 Stat. 2402; Pub. L. 104–193, title I, § 108(g)(2), Aug. 22, 1996, 110 Stat. 2168; Pub. L. 105–33, title IV, § 4757(a), Aug. 5, 1997, 111 Stat. 527; Pub. L. 106–554, § 1(a)(6) [title VII, § 703(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–574; Pub. L. 111–148, title II, § 2601(b)(2), title X, § 10201(i), Mar. 23, 2010, 124 Stat. 315, 922; Pub. L. 113–183, title III, § 302(b), Sept. 29, 2014, 128 Stat. 1945.)

CITE AS: 42 USC 1315

§ 1315a. Center for Medicare and Medicaid Innovation
(a) Center for Medicare and Medicaid Innovation established
(1) In general
(2) Deadline
(3) Consultation
(4) DefinitionsIn this section:
(A) Applicable individualThe term “applicable individual” means—
(i) an individual who is entitled to, or enrolled for, benefits under part A of subchapter XVIII or enrolled for benefits under part B of such subchapter;
(ii) an individual who is eligible for medical assistance under subchapter XIX, under a State plan or waiver; or
(iii) an individual who meets the criteria of both clauses (i) and (ii).
(B) Applicable subchapter
(5) Testing within certain geographic areas
(b) Testing of models (phase I)
(1) In general
(2) Selection of models to be tested
(A) In general
(B) OpportunitiesThe models described in this subparagraph are the following models:
(i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, medical homes that address women’s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment.
(ii) Contracting directly with groups of providers of services and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payment or salary-based payment.
(iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one of the following:(I) An inability to perform 2 or more activities of daily living.(II) Cognitive impairment, including dementia.
(iv) Promote 1
1 So in original. Probably should be “Promoting”.
care coordination between providers of services and suppliers that transition health care providers away from fee-for-service based reimbursement and toward salary-based payment.
(v) Supporting care coordination for chronically-ill applicable individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology.
(vi) Varying payment to physicians who order advanced diagnostic imaging services (as defined in section 1395m(e)(1)(B) of this title) according to the physician’s adherence to appropriateness criteria for the ordering of such services, as determined in consultation with physician specialty groups and other relevant stakeholders.
(vii) Utilizing medication therapy management services, such as those described in section 299b–35 of this title.
(viii) Establishing community-based health teams to support small-practice medical homes by assisting the primary care practitioner in chronic care management, including patient self-management, activities.
(ix) Assisting applicable individuals in making informed health care choices by paying providers of services and suppliers for using patient decision-support tools, including tools that meet the standards developed and identified under section 299b–36(c)(2)(A) of this title, that improve applicable individual and caregiver understanding of medical treatment options.
(x) Allowing States to test and evaluate fully integrating care for dual eligible individuals in the State, including the management and oversight of all funds under the applicable subchapters with respect to such individuals.
(xi) Allowing States to test and evaluate systems of all-payer payment reform for the medical care of residents of the State, including dual eligible individuals.
(xii) Aligning nationally recognized, evidence-based guidelines of cancer care with payment incentives under subchapter XVIII in the areas of treatment planning and follow-up care planning for applicable individuals described in clause (i) or (iii) of subsection (a)(4)(A) with cancer, including the identification of gaps in applicable quality measures.
(xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or skilled nursing care during an inpatient stay and the 30 days immediately following discharge.
(xiv) Funding home health providers who offer chronic care management services to applicable individuals in cooperation with interdisciplinary teams.
(xv) Promoting improved quality and reduced cost by developing a collaborative of high-quality, low-cost health care institutions that is responsible for—(I) developing, documenting, and disseminating best practices and proven care methods;(II) implementing such best practices and proven care methods within such institutions to demonstrate further improvements in quality and efficiency; and(III) providing assistance to other health care institutions on how best to employ such best practices and proven care methods to improve health care quality and lower costs.
(xvi) Facilitate inpatient care, including intensive care, of hospitalized applicable individuals at their local hospital through the use of electronic monitoring by specialists, including intensivists and critical care specialists, based at integrated health systems.
(xvii) Promoting greater efficiencies and timely access to outpatient services (such as outpatient physical therapy services) through models that do not require a physician or other health professional to refer the service or be involved in establishing the plan of care for the service, when such service is furnished by a health professional who has the authority to furnish the service under existing State law.
(xviii) Establishing comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities, that, through their structure, operations, and joint-activity deliver a full spectrum of integrated and comprehensive health care services to applicable individuals while also incorporating innovative methods for the clinical training of future health care professionals.
(xix) Utilizing, in particular in entities located in medically underserved areas and facilities of the Indian Health Service (whether operated by such Service or by an Indian tribe or tribal organization (as those terms are defined in section 1603 of title 25)), telehealth services—(I) in treating behavioral health issues (such as post-traumatic stress disorder) and stroke; and(II) to improve the capacity of non-medical providers and non-specialized medical providers to provide health services for patients with chronic complex conditions.
(xx) Utilizing a diverse network of providers of services and suppliers to improve care coordination for applicable individuals described in subsection (a)(4)(A)(i) with 2 or more chronic conditions and a history of prior-year hospitalization through interventions developed under the Medicare Coordinated Care Demonstration Project under section 4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b–1 note).
(xxi) Focusing primarily on physicians’ services (as defined in section 1395w–4(j)(3) of this title) furnished by physicians who are not primary care practitioners.
(xxii) Focusing on practices of 15 or fewer professionals.
(xxiii) Focusing on risk-based models for small physician practices which may involve two-sided risk and prospective patient assignment, and which examine risk-adjusted decreases in mortality rates, hospital readmissions rates, and other relevant and appropriate clinical measures.
(xxiv) Focusing primarily on subchapter XIX, working in conjunction with the Center for Medicaid and CHIP Services.
(xxv) Providing, for the adoption and use of certified EHR technology (as defined in section 1395w–4(o)(4) of this title) to improve the quality and coordination of care through the electronic documentation and exchange of health information, incentive payments to behavioral health providers (such as psychiatric hospitals (as defined in section 1395x(f) of this title), community mental health centers (as defined in section 1395x(ff)(3)(B) of this title), hospitals that participate in a State plan under subchapter XIX or a waiver of such plan, treatment facilities that participate in such a State plan or such a waiver, mental health or substance use disorder providers that participate in such a State plan or such a waiver, clinical psychologists (as defined in section 1395x(ii) of this title), nurse practitioners (as defined in section 1395x(aa)(5) of this title) with respect to the provision of psychiatric services, and clinical social workers (as defined in section 1395x(hh)(1) of this title)).
(xxvi) Supporting ways to familiarize individuals with the availability of coverage under part B of subchapter XVIII for qualified psychologist services (as defined in section 1395x(ii) of this title).
(xxvii) Exploring ways to avoid unnecessary hospitalizations or emergency department visits for mental and behavioral health services (such as for treating depression) through use of a 24-hour, 7-day a week help line that may inform individuals about the availability of treatment options, including the availability of qualified psychologist services (as defined in section 1395x(ii) of this title).
(C) Additional factors for considerationIn selecting models for testing under subparagraph (A), the CMI may consider the following additional factors:
(i) Whether the model includes a regular process for monitoring and updating patient care plans in a manner that is consistent with the needs and preferences of applicable individuals.
(ii) Whether the model places the applicable individual, including family members and other informal caregivers of the applicable individual, at the center of the care team of the applicable individual.
(iii) Whether the model provides for in-person contact with applicable individuals.
(iv) Whether the model utilizes technology, such as electronic health records and patient-based remote monitoring systems, to coordinate care over time and across settings.
(v) Whether the model provides for the maintenance of a close relationship between care coordinators, primary care practitioners, specialist physicians, community-based organizations, and other providers of services and suppliers.
(vi) Whether the model relies on a team-based approach to interventions, such as comprehensive care assessments, care planning, and self-management coaching.
(vii) Whether, under the model, providers of services and suppliers are able to share information with patients, caregivers, and other providers of services and suppliers on a real time basis.
(viii) Whether the model demonstrates effective linkage with other public sector payers, private sector payers, or statewide payment models.
(3) Budget neutrality
(A) Initial period
(B) Termination or modificationThe Secretary shall terminate or modify the design and implementation of a model unless the Secretary determines (and the Chief Actuary of the Centers for Medicare & Medicaid Services, with respect to program spending under the applicable subchapter, certifies), after testing has begun, that the model is expected to—
(i) improve the quality of care (as determined by the Administrator of the Centers for Medicare & Medicaid Services) without increasing spending under the applicable subchapter;
(ii) reduce spending under the applicable subchapter without reducing the quality of care; or
(iii) improve the quality of care and reduce spending.
Such termination may occur at any time after such testing has begun and before completion of the testing.
(4) Evaluation
(A) In generalThe Secretary shall conduct an evaluation of each model tested under this subsection. Such evaluation shall include an analysis of—
(i) the quality of care furnished under the model, including the measurement of patient-level outcomes and patient-centeredness criteria determined appropriate by the Secretary; and
(ii) the changes in spending under the applicable subchapters by reason of the model.
(B) Information
(C) Measure selection
(c) Expansion of models (phase II)Taking into account the evaluation under subsection (b)(4), the Secretary may, through rulemaking, expand (including implementation on a nationwide basis) the duration and the scope of a model that is being tested under subsection (b) or a demonstration project under section 1395cc–3 of this title, to the extent determined appropriate by the Secretary, if—
(1) the Secretary determines that such expansion is expected to—
(A) reduce spending under applicable 3
3 So in original. Probably should be preceded by “the”.
subchapter without reducing the quality of care; or
(B) improve the quality of patient care without increasing spending;
(2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce (or would not result in any increase in) net program spending under applicable subchapters; and
(3) the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under the applicable subchapter for applicable individuals.
In determining which models or demonstration projects to expand under the preceding sentence, the Secretary shall focus on models and demonstration projects that improve the quality of patient care and reduce spending.
(d) Implementation
(1) Waiver authority
(2) Limitations on reviewThere shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise of—
(A) the selection of models for testing or expansion under this section;
(B) the selection of organizations, sites, or participants to test those models selected;
(C) the elements, parameters, scope, and duration of such models for testing or dissemination;
(D) determinations regarding budget neutrality under subsection (b)(3);
(E) the termination or modification of the design and implementation of a model under subsection (b)(3)(B); and
(F) determinations about expansion of the duration and scope of a model under subsection (c), including the determination that a model is not expected to meet criteria described in paragraph (1) or (2) of such subsection.
(3) Administration
(e) Application to CHIP
(f) Funding
(1) In generalThere are appropriated, from amounts in the Treasury not otherwise appropriated—
(A) $5,000,000 for the design, implementation, and evaluation of models under subsection (b) for fiscal year 2010;
(B) $10,000,000,000 for the activities initiated under this section for the period of fiscal years 2011 through 2019; and
(C) the amount described in subparagraph (B) for the activities initiated under this section for each subsequent 10-year fiscal period (beginning with the 10-year fiscal period beginning with fiscal year 2020).
Amounts appropriated under the preceding sentence shall remain available until expended.
(2) Use of certain funds
(g) Report to Congress
(Aug. 14, 1935, ch. 531, title XI, § 1115A, as added and amended Pub. L. 111–148, title III, § 3021(a), title X, § 10306, Mar. 23, 2010, 124 Stat. 389, 939; Pub. L. 114–10, title I, § 101(e)(4), Apr. 16, 2015, 129 Stat. 122; Pub. L. 114–85, § 1, Nov. 5, 2015, 129 Stat. 674; Pub. L. 115–271, title VI, §§ 6001, 6085(a), Oct. 24, 2018, 132 Stat. 3976, 3996.)

CITE AS: 42 USC 1315a

§ 1315b. Providing Federal coverage and payment coordination for dual eligible beneficiaries
(a) Establishment of Federal Coordinated Health Care Office
(1) In general
(2) Establishment and reporting to CMS administrator
The Federal Coordinated Health Care Office—
(A) shall be established within the Centers for Medicare & Medicaid Services; and
(B) have as the Office 1
1 So in original.
a Director who shall be appointed by, and be in direct line of authority to, the Administrator of the Centers for Medicare & Medicaid Services.
(b) Purpose
The purpose of the Federal Coordinated Health Care Office is to bring together officers and employees of the Medicare and Medicaid programs at the Centers for Medicare & Medicaid Services in order to—
(1) more effectively integrate benefits under the Medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] and the Medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.]; and
(2) improve the coordination between the Federal Government and States for individuals eligible for benefits under both such programs in order to ensure that such individuals get full access to the items and services to which they are entitled under titles XVIII and XIX of the Social Security Act.
(c) Goals
The goals of the Federal Coordinated Health Care Office are as follows:
(1) Providing dual eligible individuals full access to the benefits to which such individuals are entitled under the Medicare and Medicaid programs.
(2) Simplifying the processes for dual eligible individuals to access the items and services they are entitled to under the Medicare and Medicaid programs.
(3) Improving the quality of health care and long-term services for dual eligible individuals.
(4) Increasing dual eligible individuals’ understanding of and satisfaction with coverage under the Medicare and Medicaid programs.
(5) Eliminating regulatory conflicts between rules under the Medicare and Medicaid programs.
(6) Improving care continuity and ensuring safe and effective care transitions for dual eligible individuals.
(7) Eliminating cost-shifting between the Medicare and Medicaid program and among related health care providers.
(8) Improving the quality of performance of providers of services and suppliers under the Medicare and Medicaid programs.
(d) Specific responsibilities
The specific responsibilities of the Federal Coordinated Health Care Office are as follows:
(1) Providing States, specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of the Social Security Act (42 U.S.C. 1395w–28(b)(6))), physicians and other relevant entities or individuals with the education and tools necessary for developing programs that align benefits under the Medicare and Medicaid programs for dual eligible individuals.
(2) Supporting State efforts to coordinate and align acute care and long-term care services for dual eligible individuals with other items and services furnished under the Medicare program.
(3) Providing support for coordination of contracting and oversight by States and the Centers for Medicare & Medicaid Services with respect to the integration of the Medicare and Medicaid programs in a manner that is supportive of the goals described in paragraph (3).2
2 So in original. Probably should be “subsection (c).”
(4) To consult and coordinate with the Medicare Payment Advisory Commission established under section 1805 of the Social Security Act (42 U.S.C. 1395b–6) and the Medicaid and CHIP Payment and Access Commission established under section 1900 of such Act (42 U.S.C. 1396) with respect to policies relating to the enrollment in, and provision of, benefits to dual eligible individuals under the Medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] and the Medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.].
(5) To study the provision of drug coverage for new full-benefit dual eligible individuals (as defined in section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6)),3
3 So in original. Another closing parenthesis probably should precede the comma.
as well as to monitor and report annual total expenditures, health outcomes, and access to benefits for all dual eligible individuals.
(6) To act as a designated contact for States under subsection (f)(8)(A) of section 1859 of the Social Security Act (42 U.S.C. 1395w–28) with respect to the integration of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) of such section.
(7) To be responsible, subject to the final approval of the Secretary, for developing regulations and guidance related to the implementation of a unified grievance and appeals process as described in subparagraphs (B) and (C) of section 1859(f)(8) of the Social Security Act (42 U.S.C. 1395w–28(f)(8)).
(8) To be responsible, subject to the final approval of the Secretary, for developing regulations and guidance related to the integration or alignment of policy and oversight under the Medicare program under title XVIII of such Act [42 U.S.C. 1395 et seq.] and the Medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.] regarding specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) of such section 1859.
(e) Report
(f) Dual eligible individual defined
(Pub. L. 111–148, title II, § 2602, Mar. 23, 2010, 124 Stat. 315; Pub. L. 115–123, div. E, title III, § 50311(b)(2), Feb. 9, 2018, 132 Stat. 196.)

CITE AS: 42 USC 1315b

§ 1316. Administrative and judicial review of public assistance determinations
(a) Determination of conformity with requirements for approval; petition for reconsideration; hearing; time limitations; review by court of appeals
(1) Whenever a State plan is submitted to the Secretary by a State for approval under subchapter I, X, XIV, XVI, or XIX, he shall, not later than 90 days after the date the plan is submitted to him, make a determination as to whether it conforms to the requirements for approval under such subchapter. The 90-day period provided herein may be extended by written agreement of the Secretary and the affected State.
(2) Any State dissatisfied with a determination of the Secretary under paragraph (1) of this subsection with respect to any plan may, within 60 days after it has been notified of such determination, file a petition with the Secretary for reconsideration of the issue of whether such plan conforms to the requirements for approval under such subchapter. Within 30 days after receipt of such a petition, the Secretary shall notify the State of the time and place at which a hearing will be held for the purpose of reconsidering such issue. Such hearing shall be held not less than 20 days nor more than 60 days after the date notice of such hearing is furnished to such State, unless the Secretary and such State agree in writing to holding the hearing at another time. The Secretary shall affirm, modify, or reverse his original determination within 60 days of the conclusion of the hearing.
(3) Any State which is dissatisfied with a final determination made by the Secretary on such a reconsideration or a final determination of the Secretary under section 304, 1204, 1354, 1384, or 1396c of this title may, within 60 days after it has been notified of such determination, file with the United States court of appeals for the circuit in which such State is located a petition for review of such determination. A copy of the petition shall be forthwith transmitted by the clerk of the court to the Secretary. The Secretary thereupon shall file in the court the record of the proceedings on which he based his determination as provided in section 2112 of title 28.
(4) The findings of fact by the Secretary, if supported by substantial evidence, shall be conclusive; but the court, for good cause shown, may remand the case to the Secretary to take further evidence, and the Secretary may thereupon make new or modified findings of fact and may modify his previous action, and shall certify to the court the transcript and record of the further proceedings. Such new or modified findings of fact shall likewise be conclusive if supported by substantial evidence.
(5) The court shall have jurisdiction to affirm the action of the Secretary or to set it aside, in whole or in part. The judgment of the court shall be subject to review by the Supreme Court of the United States upon certiorari or certification as provided in section 1254 of title 28.
(b) Amendment of plans
(c) Restitution when Secretary reverses his determination
(d) Disallowance of items covered under other subchapters
(e) Disallowance of items covered under subchapter XIX
(1) Whenever the Secretary determines that any item or class of items on account of which Federal financial participation is claimed under subchapter XIX shall be disallowed for such participation, the State shall be entitled to and upon request shall receive a reconsideration of the disallowance, provided that such request is made during the 60-day period that begins on the date the State receives notice of the disallowance.
(2)
(A) A State may appeal a disallowance of a claim for federal 2
2 So in original. Probably should be capitalized.
financial participation under subchapter XIX by the Secretary, or an unfavorable reconsideration of a disallowance, during the 60-day period that begins on the date the State receives notice of the disallowance or of the unfavorable reconsideration, in whole or in part, to the Departmental Appeals Board, established in the Department of Health and Human Services (in this paragraph referred to as the “Board”), by filing a notice of appeal with the Board.
(B) The Board shall consider a State’s appeal of a disallowance of such a claim (or of an unfavorable reconsideration of a disallowance) on the basis of such documentation as the State may submit and as the Board may require to support the final decision of the Board. In deciding whether to uphold a disallowance of such a claim or any portion thereof, the Board shall be bound by all applicable laws and regulations and shall conduct a thorough review of the issues, taking into account all relevant evidence. The Board’s decision of an appeal under subparagraph (A) shall be the final decision of the Secretary and shall be subject to reconsideration by the Board only upon motion of either party filed during the 60-day period that begins on the date of the Board’s decision or to judicial review in accordance with subparagraph (C).
(C) A State may obtain judicial review of a decision of the Board by filing an action in any United States District Court located within the appealing State (or, if several States jointly appeal the disallowance of claims for Federal financial participation under section 1396b of this title, in any United States District Court that is located within any State that is a party to the appeal) or the United States District Court for the District of Columbia. Such an action may only be filed—
(i) if no motion for reconsideration was filed within the 60-day period specified in subparagraph (B), during such 60-day period; or
(ii) if such a motion was filed within such period, during the 60-day period that begins on the date of the Board’s decision on such motion.
(Aug. 14, 1935, ch. 531, title XI, § 1116, as added Pub. L. 89–97, title IV, § 404(a), July 30, 1965, 79 Stat. 419; amended Pub. L. 90–248, title II, § 241(c)(5), Jan. 2, 1968, 81 Stat. 917; Pub. L. 93–233, § 18(z–2)(1)(C), Dec. 31, 1973, 87 Stat. 974; Pub. L. 93–647, § 3(d), Jan. 4, 1975, 88 Stat. 2349; Pub. L. 97–35, title XXIII, § 2353(h), Aug. 13, 1981, 95 Stat. 872; Pub. L. 98–369, div. B, title III, § 2354(c)(2), title VI, § 2663(e)(6), July 18, 1984, 98 Stat. 1102, 1168; Pub. L. 104–193, title I, § 108(g)(3), Aug. 22, 1996, 110 Stat. 2168; Pub. L. 110–275, title II, § 204(a), (b), July 15, 2008, 122 Stat. 2592, 2593.)

CITE AS: 42 USC 1316

§ 1317. Appointment of the Administrator and Chief Actuary of the Centers for Medicare & Medicaid Services
(a) The Administrator of the Centers for Medicare & Medicaid Services shall be appointed by the President by and with the advice and consent of the Senate.
(b)
(1) There is established in the Centers for Medicare & Medicaid Services the position of Chief Actuary. The Chief Actuary shall be appointed by, and in direct line of authority to, the Administrator of such Centers. The Chief Actuary shall be appointed from among individuals who have demonstrated, by their education and experience, superior expertise in the actuarial sciences. The Chief Actuary shall exercise such duties as are appropriate for the office of the Chief Actuary and in accordance with professional standards of actuarial independence. The Chief Actuary may be removed only for cause.
(2) The Chief Actuary shall be compensated at the highest rate of basic pay for the Senior Executive Service under section 5382(b) of title 5.
(3) In the office of the Chief Actuary there shall be an actuary whose duties relate exclusively to the programs under parts C and D of subchapter XVIII and related provisions of such subchapter.
(Aug. 14, 1935, ch. 531, title XI, § 1117, as added Pub. L. 98–369, div. B, title III, § 2332(a), July 18, 1984, 98 Stat. 1088; amended Pub. L. 105–33, title IV, § 4643, Aug. 5, 1997, 111 Stat. 487; Pub. L. 108–173, title IX, § 900(c), (e)(1)(A), Dec. 8, 2003, 117 Stat. 2370.)

CITE AS: 42 USC 1317

§ 1318. Alternative Federal payment with respect to public assistance expenditures

In the case of any State which has in effect a plan approved under subchapter XIX for any calendar quarter, the total of the payments to which such State is entitled for such quarter, and for each succeeding quarter in the same fiscal year (which for purposes of this section means the 4 calendar quarters ending with September 30), under paragraphs (1) and (2) of sections 303(a),1

1 See References in Text note below.
1203(a),1 1353(a),1 and 1383(a) 1 of this title shall, at the option of the State, be determined by application of the Federal medical assistance percentage (as defined in section 1396d of this title), instead of the percentages provided under each such section, to the expenditures under its State plans approved under subchapters I, X, XIV, and XVI, which would be included in determining the amounts of the Federal payments to which such State is entitled under such sections, but without regard to any maximum on the dollar amounts per recipient which may be counted under such sections. For purposes of the preceding sentence, the term “Federal medical assistance percentage” shall, in the case of Puerto Rico, the Virgin Islands, and Guam, mean 75 per centum.

(Aug. 14, 1935, ch. 531, title XI, § 1118, as added Pub. L. 89–97, title IV, § 411, July 30, 1965, 79 Stat. 423; amended Pub. L. 90–248, title II, § 241(c)(7), Jan. 2, 1968, 81 Stat. 917; Pub. L. 94–273, § 2(23), Apr. 21, 1976, 90 Stat. 376; Pub. L. 95–600, title VIII, § 802(a), Nov. 6, 1978, 92 Stat. 2945; Pub. L. 96–272, title III, § 305(c), June 17, 1980, 94 Stat. 530; Pub. L. 100–485, title VI, § 601(c)(3), Oct. 13, 1988, 102 Stat. 2408; Pub. L. 104–193, title I, § 108(g)(4), Aug. 22, 1996, 110 Stat. 2168.)

CITE AS: 42 USC 1318

§ 1319. Federal participation in payments for repairs to home owned by recipient of aid or assistance
In the case of an expenditure for repairing the home owned by an individual who is receiving aid or assistance, other than medical assistance to the aged, under a State plan approved under subchapter I, X, XIV, or XVI, if—
(1) the State agency or local agency administering the plan approved under such subchapter has made a finding (prior to making such expenditure) that (A) such home is so defective that continued occupancy is unwarranted, (B) unless repairs are made to such home, rental quarters will be necessary for such individual, and (C) the cost of rental quarters to take care of the needs of such individual (including his spouse living with him in such home and any other individual whose needs were taken into account in determining the need of such individual) would exceed (over such time as the Secretary may specify) the cost of repairs needed to make such home habitable together with other costs attributable to continued occupancy of such home, and
(2) no such expenditures were made for repairing such home pursuant to any prior finding under this section,
the amount paid to any such State for any quarter under section 303(a), 1203(a), 1353(a), or 1383(a) of this title shall be increased by 50 per centum of such expenditures, except that the excess above $500 expended with respect to any one home shall not be included in determining such expenditures.
(Aug. 14, 1935, ch. 531, title XI, § 1119, as added Pub. L. 90–248, title II, § 209(a), Jan. 2, 1968, 81 Stat. 894; amended Pub. L. 104–193, title I, § 108(g)(5), Aug. 22, 1996, 110 Stat. 2168.)

CITE AS: 42 USC 1319

§ 1320. Approval of certain projects

No payment shall be made under this chapter with respect to any experimental, pilot, demonstration, or other project all or any part of which is wholly financed with Federal funds made available under this chapter (without any State, local, or other non-Federal financial participation) unless such project shall have been personally approved by the Secretary or Deputy Secretary of Health and Human Services.

(Aug. 14, 1935, ch. 531, title XI, § 1120, as added Pub. L. 90–248, title II, § 249, Jan. 2, 1968, 81 Stat. 919; amended Pub. L. 93–608, § 2(5), Jan. 2, 1975, 88 Stat. 1971; Pub. L. 97–375, title I, § 107(a), Dec. 21, 1982, 96 Stat. 1820; Pub. L. 98–369, div. B, title VI, § 2663(j)(2)(D)(v), July 18, 1984, 98 Stat. 1170; Pub. L. 101–509, title V, § 529 [title I, § 112(c)], Nov. 5, 1990, 104 Stat. 1427, 1454.)

CITE AS: 42 USC 1320

§ 1320a. Uniform reporting systems for health services facilities and organizations
(a) Establishment; criteria for regulations; requirements for hospitals
For the purposes of reporting the cost of services provided by, of planning, and of measuring and comparing the efficiency of and effective use of services in, hospitals, skilled nursing facilities, intermediate care facilities, home health agencies, health maintenance organizations, and other types of health services facilities and organizations to which payment may be made under this chapter, the Secretary shall establish by regulation, for each such type of health services facility or organization, a uniform system for the reporting by a facility or organization of that type of the following information:
(1) The aggregate cost of operation and the aggregate volume of services.
(2) The costs and volume of services for various functional accounts and subaccounts.
(3) Rates, by category of patient and class of purchaser.
(4) Capital assets, as defined by the Secretary, including (as appropriate) capital funds, debt service, lease agreements used in lieu of capital funds, and the value of land, facilities, and equipment.
(5) Discharge and bill data.
The uniform reporting system for a type of health services facility or organization shall provide for appropriate variation in the application of the system to different classes of facilities or organizations within that type and shall be established, to the extent practicable, consistent with the cooperative system for producing comparable and uniform health information and statistics described in section 242k(e)(1) of this title. In reporting under such a system, hospitals shall employ such chart of accounts, definitions, principles, and statistics as the Secretary may prescribe in order to reach a uniform reconciliation of financial and statistical data for specified uniform reports to be provided to the Secretary.
(b) Monitoring, etc., of systems by Secretary
The Secretary shall—
(1) monitor the operation of the systems established under subsection (a);
(2) assist with and support demonstrations and evaluations of the effectiveness and cost of the operation of such systems and encourage State adoption of such systems; and
(3) periodically revise such systems to improve their effectiveness and diminish their cost.
(c) Availability of information to appropriate agencies and organizations
(Aug. 14, 1935, ch. 531, title XI, § 1121, as added Pub. L. 95–142, § 19(a), Oct. 25, 1977, 91 Stat. 1203.)

CITE AS: 42 USC 1320a

§ 1320a–1. Limitation on use of Federal funds for capital expenditures
(a) Use of reimbursement for planning activities for health services and facilities
(b) Agreement between Secretary and State for submission of proposed capital expenditures related to health care facilities and procedures for appeal from recommendationsThe Secretary, after consultation with the Governor (or other chief executive officer) and with appropriate local public officials, shall make an agreement with any State which is able and willing to do so under which a designated planning agency (which shall be an agency described in clause (ii) of subsection (d)(1)(B) that has a governing body or advisory board at least half of whose members represent consumer interests) will—
(1) make, and submit to the Secretary together with such supporting materials as he may find necessary, findings and recommendations with respect to capital expenditures proposed by or on behalf of any health care facility in such State within the field of its responsibilities,
(2) receive from other agencies described in clause (ii) of subsection (d)(1)(B), and submit to the Secretary together with such supporting material as he may find necessary, the findings and recommendations of such other agencies with respect to capital expenditures proposed by or on behalf of health care facilities in such State within the fields of their respective responsibilities, and
(3) establish and maintain procedures pursuant to which a person proposing any such capital expenditure may appeal a recommendation by the designated agency and will be granted an opportunity for a fair hearing by such agency or person other than the designated agency as the Governor (or other chief executive officer) may designate to hold such hearings,
whenever and to the extent that the findings of such designated agency or any such other agency indicate that any such expenditure is not consistent with the standards, criteria, or plans developed pursuant to the Public Health Service Act [42 U.S.C. 201 et seq.] to meet the need for adequate health care facilities in the area covered by the plan or plans so developed.
(c) Manner of payment to States for carrying out agreement
(d) Determination of amount of exclusions from Federal payments
(1) Except as provided in paragraph (2), if the Secretary determines that—
(A) neither the planning agency designated in the agreement described in subsection (b) nor an agency described in clause (ii) of subparagraph (B) of this paragraph had been given notice of any proposed capital expenditure (in accordance with such procedure or in such detail as may be required by such agency) at least 60 days prior to obligation for such expenditure; or
(B)
(i) the planning agency so designated or an agency so described had received such timely notice of the intention to make such capital expenditure and had, within a reasonable period after receiving such notice and prior to obligation for such expenditure, notified the person proposing such expenditure that the expenditure would not be in conformity with the standards, criteria, or plans developed by such agency or any other agency described in clause (ii) for adequate health care facilities in such State or in the area for which such other agency has responsibility, and
(ii) the planning agency so designated had, prior to submitting to the Secretary the findings referred to in subsection (b)—(I) consulted with, and taken into consideration the findings and recommendations of, the State planning agencies established pursuant to sections 314(a) and 604(a) of the Public Health Service Act [42 U.S.C. 246(a), 291d(a)] (to the extent that either such agency is not the agency so designated) as well as the public or nonprofit private agency or organization responsible for the comprehensive regional, metropolitan area, or other local area plan or plans referred to in section 314(b) of the Public Health Service Act [42 U.S.C. 246(b)] and covering the area in which the health care facility proposing such capital expenditure is located (where such agency is not the agency designated in the agreement), or, if there is no such agency, such other public or nonprofit private agency or organization (if any) as performs, as determined in accordance with criteria included in regulations, similar functions, and(II) granted to the person proposing such capital expenditure an opportunity for a fair hearing with respect to such findings;
then, for such period as he finds necessary in any case to effectuate the purpose of this section, he shall, in determining the Federal payments to be made under subchapters XVIII and XIX with respect to services furnished in the health care facility for which such capital expenditure is made, not include any amount which is attributable to depreciation, interest on borrowed funds, a return on equity capital (in the case of proprietary facilities), or other expenses related to such capital expenditure. With respect to any organization which is reimbursed on a per capita or a fixed fee or negotiated rate basis, in determining the Federal payments to be made under subchapters XVIII and XIX, the Secretary shall exclude an amount which in his judgment is a reasonable equivalent to the amount which would otherwise be excluded under this subsection if payment were to be made on other than a per capita or a fixed fee or negotiated rate basis.
(2) If the Secretary, after submitting the matters involved to the advisory council established or designated under subsection (i), determines that an exclusion of expenses related to any capital expenditure of any health care facility would discourage the operation or expansion of such facility which has demonstrated to his satisfaction proof of capability to provide comprehensive health care services (including institutional services) efficiently, effectively, and economically, or would otherwise be inconsistent with the effective organization and delivery of health services or the effective administration of subchapter XVIII or XIX, he shall not exclude such expenses pursuant to paragraph (1).
(e) Treatment of lease or comparable arrangement of any facility or equipment for a facility in determining amount of exclusions from Federal payments
(f) Reconsideration by Secretary of determinations
(g) “Capital expenditure” defined
(h) Applicability to Christian Science sanatoriums
(i) National advisory council; establishment or designation of existing council; functions; consultations with other appropriate national advisory councils; composition; compensation and travel expenses
(1) The Secretary shall establish a national advisory council, or designate an appropriate existing national advisory council, to advise and assist him in the preparation of general regulations to carry out the purposes of this section and on policy matters arising in the administration of this section, including the coordination of activities under this section with those under other parts of this chapter or under other Federal or federally assisted health programs.
(2) The Secretary shall make appropriate provision for consultation between and coordination of the work of the advisory council established or designated under paragraph (1) and the Federal Hospital Council, the National Advisory Health Council, the Health Insurance Benefits Advisory Council, and other appropriate national advisory councils with respect to matters bearing on the purposes and administration of this section and the coordination of activities under this section with related Federal health programs.
(3) If an advisory council is established by the Secretary under paragraph (1), it shall be composed of members who are not otherwise in the regular full-time employ of the United States, and who shall be appointed by the Secretary without regard to the civil service laws from among leaders in the fields of the fundamental sciences, the medical sciences, and the organization, delivery, and financing of health care, and persons who are State or local officials or are active in community affairs or public or civic affairs or who are representative of minority groups. Members of such advisory council, while attending meetings of the council or otherwise serving on business of the council, shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding the maximum rate specified at the time of such service for grade GS–18 in section 5332 of title 5, including traveltime, and while away from their homes or regular places of business they may also be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5703 of such title 5 for persons in the Government service employed intermittently.
(j) Capital expenditure review exception for eligible organization health care facilitiesA capital expenditure made by or on behalf of a health care facility shall not be subject to review pursuant to this section if 75 percent of the patients who can reasonably be expected to use the service with respect to which the capital expenditure is made will be individuals enrolled in an eligible organization as defined in section 1395mm(b) of this title, and if the Secretary determines that such capital expenditure is for services and facilities which are needed by such organization in order to operate efficiently and economically and which are not otherwise readily accessible to such organization because—
(1) the facilities do not provide common services at the same site (as usually provided by the organization),
(2) the facilities are not available under a contract of reasonable duration,
(3) full and equal medical staff privileges in the facilities are not available,
(4) arrangements with such facilities are not administratively feasible, or
(5) the purchase of such services is more costly than if the organization provided the services directly.
(Aug. 14, 1935, ch. 531, title XI, § 1122, as added Pub. L. 92–603, title II, § 221(a), Oct. 30, 1972, 86 Stat. 1386; amended Pub. L. 93–233, § 18(z), (z–1), Dec. 31, 1973, 87 Stat. 973; Pub. L. 95–559, § 14(b), Nov. 1, 1978, 92 Stat. 2141; Pub. L. 96–32, § 2(c), July 10, 1979, 93 Stat. 82; Pub. L. 97–35, title XXI, § 2193(c)(3), Aug. 13, 1981, 95 Stat. 827; Pub. L. 97–248, title I, § 137(a)(5), Sept. 3, 1982, 96 Stat. 376; Pub. L. 98–21, title VI, § 607(a), (b)(1), (c), Apr. 20, 1983, 97 Stat. 171, 172; Pub. L. 98–369, div. B, title III, § 2354(a)(1), (2), July 18, 1984, 98 Stat. 1100; Pub. L. 105–33, title IV, § 4454(c)(1), Aug. 5, 1997, 111 Stat. 431.)

CITE AS: 42 USC 1320a-1

§ 1320a–1a. Transferred

CITE AS: 42 USC 1320a-1a

§ 1320a–2. Effect of failure to carry out State plan

In an action brought to enforce a provision of this chapter, such provision is not to be deemed unenforceable because of its inclusion in a section of this chapter requiring a State plan or specifying the required contents of a State plan. This section is not intended to limit or expand the grounds for determining the availability of private actions to enforce State plan requirements other than by overturning any such grounds applied in Suter v. Artist M., 112 S. Ct. 1360 (1992), but not applied in prior Supreme Court decisions respecting such enforceability; provided, however, that this section is not intended to alter the holding in Suter v. Artist M. that section 671(a)(15) of this title is not enforceable in a private right of action.

(Aug. 14, 1935, ch. 531, title XI, § 1123, as added Pub. L. 103–382, title V, § 555(a), Oct. 20, 1994, 108 Stat. 4057.)

CITE AS: 42 USC 1320a-2

§ 1320a–2a. Reviews of child and family services programs, and of foster care and adoption assistance programs, for conformity with State plan requirements
(a) In generalThe Secretary, in consultation with the State agencies administering the State programs under parts B and E of subchapter IV, shall promulgate regulations for the review of such programs to determine whether such programs are in substantial conformity with—
(1) State plan requirements under such parts B and E,
(2) implementing regulations promulgated by the Secretary, and
(3) the relevant approved State plans.
(b) Elements of review systemThe regulations referred to in subsection (a) shall—
(1) specify the timetable for conformity reviews of State programs, including—
(A) an initial review of each State program;
(B) a timely review of a State program following a review in which such program was found not to be in substantial conformity; and
(C) less frequent reviews of State programs which have been found to be in substantial conformity, but such regulations shall permit the Secretary to reinstate more frequent reviews based on information which indicates that a State program may not be in conformity;
(2) specify the requirements subject to review (which shall include determining whether the State program is in conformity with the requirement of section 671(a)(27) of this title), and the criteria to be used to measure conformity with such requirements and to determine whether there is a substantial failure to so conform;
(3) specify the method to be used to determine the amount of any Federal matching funds to be withheld (subject to paragraph (4)) due to the State program’s failure to so conform, which ensures that—
(A) such funds will not be withheld with respect to a program, unless it is determined that the program fails substantially to so conform;
(B) such funds will not be withheld for a failure to so conform resulting from the State’s reliance upon and correct use of formal written statements of Federal law or policy provided to the State by the Secretary; and
(C) the amount of such funds withheld is related to the extent of the failure to so conform; and
(4) require the Secretary, with respect to any State program found to have failed substantially to so conform—
(A) to afford the State an opportunity to adopt and implement a corrective action plan, approved by the Secretary, designed to end the failure to so conform;
(B) to make technical assistance available to the State to the extent feasible to enable the State to develop and implement such a corrective action plan;
(C) to suspend the withholding of any Federal matching funds under this section while such a corrective action plan is in effect; and
(D) to rescind any such withholding if the failure to so conform is ended by successful completion of such a corrective action plan.
(c) Provisions for administrative and judicial reviewThe regulations referred to in subsection (a) shall—
(1) require the Secretary, not later than 10 days after a final determination that a program of the State is not in conformity, to notify the State of—
(A) the basis for the determination; and
(B) the amount of the Federal matching funds (if any) to be withheld from the State;
(2) afford the State an opportunity to appeal the determination to the Departmental Appeals Board within 60 days after receipt of the notice described in paragraph (1) (or, if later, after failure to continue or to complete a corrective action plan); and
(3) afford the State an opportunity to obtain judicial review of an adverse decision of the Board, within 60 days after the State receives notice of the decision of the Board, by appeal to the district court of the United States for the judicial district in which the principal or headquarters office of the agency responsible for administering the program is located.
(Aug. 14, 1935, ch. 531, title XI, § 1123A, formerly § 1123, as added Pub. L. 103–432, title II, § 203(a), Oct. 31, 1994, 108 Stat. 4454; renumbered § 1123A, Pub. L. 104–193, title V, § 504, Aug. 22, 1996, 110 Stat. 2278; amended Pub. L. 109–432, div. B, title IV, § 405(c)(1)(B)(ii), Dec. 20, 2006, 120 Stat. 2999.)

CITE AS: 42 USC 1320a-2a

§ 1320a–3. Disclosure of ownership and related information; procedure; definitions; scope of requirements
(a) In general
(1) The Secretary shall by regulation or by contract provision provide that each disclosing entity (as defined in paragraph (2)) shall—
(A) as a condition of the disclosing entity’s participation in, or certification or recertification under, any of the programs established by subchapters V, XVIII, and XIX, or
(B) as a condition for the approval or renewal of a contract or agreement between the disclosing entity and the Secretary or the appropriate State agency under any of the programs established under subchapters V, XVIII, and XIX,
supply the Secretary or the appropriate State agency with full and complete information as to the identity of each person with an ownership or control interest (as defined in paragraph (3)) in the entity or in any subcontractor (as defined by the Secretary in regulations) in which the entity directly or indirectly has a 5 per centum or more ownership interest and supply the Secretary with the 1
1 So in original. The word “the” probably should not appear.
both the employer identification number (assigned pursuant to section 6109 of the Internal Revenue Code of 1986) and social security account number (assigned under section 405(c)(2)(B) of this title) of the disclosing entity, each person with an ownership or control interest (as defined in subsection (a)(3)), and any subcontractor in which the entity directly or indirectly has a 5 percent or more ownership interest.
(2) As used in this section, the term “disclosing entity” means an entity which is—
(A) a provider of services (as defined in section 1395x(u) of this title, other than a fund), an independent clinical laboratory, a renal disease facility, a managed care entity, as defined in section 1396u–2(a)(1)(B) of this title, or a health maintenance organization (as defined in section 300e(a) of this title);
(B) an entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, items or services with respect to which payment may be claimed by the entity under any plan or program established pursuant to subchapter V or under a State plan approved under subchapter XIX; or
(C) a carrier or other agency or organization that is acting as a fiscal intermediary or agent with respect to one or more providers of services (for purposes of part A or part B of subchapter XVIII, or both, or for purposes of a State plan approved under subchapter XIX) pursuant to (i) an agreement under section 1395h of this title, (ii) a contract under section 1395u of this title, or (iii) an agreement with a single State agency administering or supervising the administration of a State plan approved under subchapter XIX.
(3) As used in this section, the term “person with an ownership or control interest” means, with respect to an entity, a person who—
(A)
(i) has directly or indirectly (as determined by the Secretary in regulations) an ownership interest of 5 per centum or more in the entity; or
(ii) is the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by the entity or any of the property or assets thereof, which whole or part interest is equal to or exceeds 5 per centum of the total property and assets of the entity; or
(B) is an officer or director of the entity, if the entity is organized as a corporation; or
(C) is a partner in the entity, if the entity is organized as a partnership.
(b) Other disclosing entities
(c) Required disclosure of ownership and additional disclosable parties information
(1) DisclosureA facility shall have the information described in paragraph (2) available—
(A) during the period beginning on March 23, 2010, and ending on the date such information is made available to the public under section 6101(b) of the Patient Protection and Affordable Care Act for submission to the Secretary, the Inspector General of the Department of Health and Human Services, the State in which the facility is located, and the State long-term care ombudsman in the case where the Secretary, the Inspector General, the State, or the State long-term care ombudsman requests such information; and
(B) beginning on the effective date of the final regulations promulgated under paragraph (3)(A), for reporting such information in accordance with such final regulations.
Nothing in subparagraph (A) shall be construed as authorizing a facility to dispose of or delete information described in such subparagraph after the effective date of the final regulations promulgated under paragraph (3)(A).
(2) Information described
(A) In generalThe following information is described in this paragraph:
(i) The information described in subsections (a) and (b), subject to subparagraph (C).
(ii) The identity of and information on—(I) each member of the governing body of the facility, including the name, title, and period of service of each such member;(II) each person or entity who is an officer, director, member, partner, trustee, or managing employee of the facility, including the name, title, and period of service of each such person or entity; and(III) each person or entity who is an additional disclosable party of the facility.
(iii) The organizational structure of each additional disclosable party of the facility and a description of the relationship of each such additional disclosable party to the facility and to one another.
(B) Special rule where information is already reported or submitted
(C) Special ruleIn applying subparagraph (A)(i)—
(i) with respect to subsections (a) and (b), “ownership or control interest” shall include direct or indirect interests, including such interests in intermediate entities; and
(ii) subsection (a)(3)(A)(ii) shall include the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured, in whole or in part, by the entity or any of the property or assets thereof, if the interest is equal to or exceeds 5 percent of the total property or assets of the entirety.
(3) Reporting
(A) In general
(B) Guidance
(4) No effect on existing reporting requirements
(5) DefinitionsIn this subsection:
(A) Additional disclosable partyThe term “additional disclosable party” means, with respect to a facility, any person or entity who—
(i) exercises operational, financial, or managerial control over the facility or a part thereof, or provides policies or procedures for any of the operations of the facility, or provides financial or cash management services to the facility;
(ii) leases or subleases real property to the facility, or owns a whole or part interest equal to or exceeding 5 percent of the total value of such real property; or
(iii) provides management or administrative services, management or clinical consulting services, or accounting or financial services to the facility.
(B) FacilityThe term “facility” means a disclosing entity which is—
(i) a skilled nursing facility (as defined in section 1395i–3(a) of this title); or
(ii) a nursing facility (as defined in section 1396r(a) of this title).
(C) Managing employee
(D) Organizational structureThe term “organizational structure” means, in the case of—
(i) a corporation, the officers, directors, and shareholders of the corporation who have an ownership interest in the corporation which is equal to or exceeds 5 percent;
(ii) a limited liability company, the members and managers of the limited liability company (including, as applicable, what percentage each member and manager has of the ownership interest in the limited liability company);
(iii) a general partnership, the partners of the general partnership;
(iv) a limited partnership, the general partners and any limited partners of the limited partnership who have an ownership interest in the limited partnership which is equal to or exceeds 10 percent;
(v) a trust, the trustees of the trust;
(vi) an individual, contact information for the individual; and
(vii) any other person or entity, such information as the Secretary determines appropriate.
(Aug. 14, 1935, ch. 531, title XI, § 1124, as added Pub. L. 95–142, § 3(a)(1), Oct. 25, 1977, 91 Stat. 1177; amended Pub. L. 96–499, title IX, § 912(a), Dec. 5, 1980, 94 Stat. 2619; Pub. L. 97–35, title XXIII, § 2353(i), Aug. 13, 1981, 95 Stat. 872; Pub. L. 100–93, § 11, Aug. 18, 1987, 101 Stat. 697; Pub. L. 105–33, title IV, §§ 4313(a), 4707(c), Aug. 5, 1997, 111 Stat. 388, 506; Pub. L. 111–148, title VI, § 6101(a), Mar. 23, 2010, 124 Stat. 699.)

CITE AS: 42 USC 1320a-3

§ 1320a–3a. Disclosure requirements for other providers under part B of Medicare
(a) Disclosure required to receive paymentNo payment may be made under part B of subchapter XVIII for items or services furnished by any disclosing part B provider unless such provider has provided the Secretary with full and complete information—
(1) on the identity of each person with an ownership or control interest in the provider or in any subcontractor (as defined by the Secretary in regulations) in which the provider directly or indirectly has a 5 percent or more ownership interest;
(2) with respect to any person identified under paragraph (1) or any managing employee of the provider—
(A) on the identity of any other entities providing items or services for which payment may be made under subchapter XVIII with respect to which such person or managing employee is a person with an ownership or control interest at the time such information is supplied or at any time during the 3-year period ending on the date such information is supplied, and
(B) as to whether any penalties, assessments, or exclusions have been assessed against such person or managing employee under section 1320a–7, 1320a–7a, or 1320a–7b of this title; and
(3) including the employer identification number (assigned pursuant to section 6109 of the Internal Revenue Code of 1986) and social security account number (assigned under section 405(c)(2)(B) of this title) of the disclosing part B provider and any person, managing employee, or other entity identified or described under paragraph (1) or (2).
(b) Updates to information supplied
(c) Verification
(1) Transmittal by HHSThe Secretary shall transmit—
(A) to the Commissioner of Social Security information concerning each social security account number (assigned under section 405(c)(2)(B) of this title), and
(B) to the Secretary of the Treasury information concerning each employer identification number (assigned pursuant to section 6109 of the Internal Revenue Code of 1986),
supplied to the Secretary pursuant to subsection (a)(3) or section 1320a–3(c) 1
1 See References in Text note below.
of this title to the extent necessary for verification of such information in accordance with paragraph (2).
(2) Verification
(3) Fees for verification
(d) DefinitionsFor purposes of this section—
(1) the term “disclosing part B provider” means any entity receiving payment on an assignment-related basis (or, for purposes of subsection (a)(3), any entity receiving payment) for furnishing items or services for which payment may be made under part B of subchapter XVIII, except that such term does not include an entity described in
(2) the term “managing employee” means, with respect to a provider, a person described in section 1320a–5(b) of this title; and
(3) the term “person with an ownership or control interest” means, with respect to a provider—
(A) a person described in section 1320a–3(a)(3) of this title, or
(B) a person who has one of the 5 largest direct or indirect ownership or control interests in the provider.
(Aug. 14, 1935, ch. 531, title XI, § 1124A, as added Pub. L. 101–508, title IV, § 4164(b)(1), Nov. 5, 1990, 104 Stat. 1388–101; amended Pub. L. 103–432, title I, § 147(f)(7)(A)(i), Oct. 31, 1994, 108 Stat. 4432; Pub. L. 105–33, title IV, § 4313(b), (c), Aug. 5, 1997, 111 Stat. 388.)

CITE AS: 42 USC 1320a-3a

§ 1320a–4. Issuance of subpenas by Comptroller General
(a) Authorization; scope; service and proof of service
(b) Contumacy or refusal to obey subpena; contempt proceedings
(c) Nondisclosure of personal medical records by Government Accountability Office
(Aug. 14, 1935, ch. 531, title XI, § 1125, as added Pub. L. 95–142, § 6, Oct. 25, 1977, 91 Stat. 1192; amended Pub. L. 108–271, § 8(b), July 7, 2004, 118 Stat. 814.)

CITE AS: 42 USC 1320a-4

§ 1320a–5. Disclosure by institutions, organizations, and agencies of owners, officers, etc., convicted of offenses related to programs; notification requirements; “managing employee” defined
(a) As a condition of participation in or certification or recertification under the programs established by subchapters XVIII,1
1 So in original. The comma probably should not appear.
and XIX, any hospital, nursing facility, or other entity (other than an individual practitioner or group of practitioners) shall be required to disclose to the Secretary or to the appropriate State agency the name of any person that is a person described in subparagraphs (A) and (B) of section 1320a–7(b)(8) of this title. The Secretary or the appropriate State agency shall promptly notify the Inspector General in the Department of Health and Human Services of the receipt from any entity of any application or request for such participation, certification, or recertification which discloses the name of any such person, and shall notify the Inspector General of the action taken with respect to such application or request.
(b) For the purposes of this section, the term “managing employee” means, with respect to an entity, an individual, including a general manager, business manager, administrator, and director, who exercises operational or managerial control over the entity, or who directly or indirectly conducts the day-to-day operations of the entity.
(Aug. 14, 1935, ch. 531, title XI, § 1126, as added Pub. L. 95–142, § 8(a), Oct. 25, 1977, 91 Stat. 1194; amended Pub. L. 97–35, title XXIII, § 2353(j), Aug. 13, 1981, 95 Stat. 873; Pub. L. 98–369, div. B, title VI, § 2663(j)(2)(D)(vi), July 18, 1984, 98 Stat. 1170; Pub. L. 100–93, § 8(b), Aug. 18, 1987, 101 Stat. 692.)

CITE AS: 42 USC 1320a-5

§ 1320a–6. Adjustments in SSI benefits on account of retroactive benefits under subchapter II
(a) Reduction in benefits
Notwithstanding any other provision of this chapter, in any case where an individual—
(1) is entitled to benefits under subchapter II that were not paid in the months in which they were regularly due; and
(2) is an individual or eligible spouse eligible for supplemental security income benefits for one or more months in which the benefits referred to in clause (1) were regularly due,
then any benefits under subchapter II that were regularly due in such month or months, or supplemental security income benefits for such month or months, which are due but have not been paid to such individual or eligible spouse shall be reduced by an amount equal to so much of the supplemental security income benefits, whether or not paid retroactively, as would not have been paid or would not be paid with respect to such individual or spouse if he had received such benefits under subchapter II in the month or months in which they were regularly due. A benefit under subchapter II shall not be reduced pursuant to the preceding sentence to the extent that any amount of such benefit would not otherwise be available for payment in full of the maximum fee which may be recovered from such benefit by an attorney pursuant to subsection (a)(4) or (b) of section 406 of this title.
(b) “Supplemental security income benefits” defined
(c) Reimbursement of the State
(Aug. 14, 1935, ch. 531, title XI, § 1127, as added Pub. L. 96–265, title V, § 501(a), June 9, 1980, 94 Stat. 469; amended Pub. L. 98–369, div. B, title VI, § 2615(a), July 18, 1984, 98 Stat. 1132; Pub. L. 101–508, title V, § 5106(b), Nov. 5, 1990, 104 Stat. 1388–268; Pub. L. 103–296, title I, § 108(b)(8), title III, § 321(f)(3)(B)(ii), Aug. 15, 1994, 108 Stat. 1483, 1542.)

CITE AS: 42 USC 1320a-6

§ 1320a–6a. Interagency coordination to improve program administration
(a) Coordination agreement
Notwithstanding any other provision of law, including section 407 of this title, the Commissioner of Social Security (referred to in this section as “the Commissioner”) and the Director of the Office of Personnel Management (referred to in this section as “the Director”) shall enter into an agreement under which a system is established to carry out the following procedure:
(1) The Director shall notify the Commissioner when any individual is determined to be entitled to a monthly disability annuity payment pursuant to subchapter V of chapter 84 of subpart G of part III of title 5 and shall certify that such individual has provided the authorization described in subsection (f).
(2) If the Commissioner determines that an individual described in paragraph (1) is also entitled to past-due benefits under section 423 of this title, the Commissioner shall notify the Director of such fact.
(3) Not later than 30 days after receiving a notification described in paragraph (2) with respect to an individual, the Director shall provide the Commissioner with the total amount of any disability annuity overpayments made to such individual, as well as any other information (in such form and manner as the Commissioner shall require) that the Commissioner determines is necessary to carry out this section.
(4) If the Director provides the Commissioner with the information described in paragraph (3) in a timely manner, the Commissioner may withhold past-due benefits under section 423 of this title to which such individual is entitled and may pay the amount described in paragraph (3) to the Office of Personnel Management for any disability annuity overpayments made to such individual.
(5) The Director shall credit any amount received under paragraph (4) with respect to an individual toward any disability annuity overpayment owed by such individual.
(b) Limitations
(1) Priority of other reductions
(2) Timely notification required
(c) Delayed payment of past-due benefits
(d) Review
(e) Disability annuity overpayment defined
(f) Authorization to withhold benefits
(g) Expenses
(Aug. 14, 1935, ch. 531, title XI, § 1127A, as added Pub. L. 114–74, title VIII, § 841(a), Nov. 2, 2015, 129 Stat. 615.)

CITE AS: 42 USC 1320a-6a

§ 1320a–7. Exclusion of certain individuals and entities from participation in Medicare and State health care programs
(a) Mandatory exclusionThe Secretary shall exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1320a–7b(f) of this title):
(1) Conviction of program-related crimes
(2) Conviction relating to patient abuse
(3) Felony conviction relating to health care fraud
(4) Felony conviction relating to controlled substance
(b) Permissive exclusionThe Secretary may exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1320a–7b(f) of this title):
(1) Conviction relating to fraudAny individual or entity that has been convicted for an offense which occurred after August 21, 1996, under Federal or State law—
(A) of a criminal offense consisting of a misdemeanor relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct—
(i) in connection with the delivery of a health care item or service, or
(ii) with respect to any act or omission in a health care program (other than those specifically described in subsection (a)(1)) operated by or financed in whole or in part by any Federal, State, or local government agency; or
(B) of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct with respect to any act or omission in a program (other than a health care program) operated by or financed in whole or in part by any Federal, State, or local government agency.
(2) Conviction relating to obstruction of an investigation or auditAny individual or entity that has been convicted, under Federal or State law, in connection with the interference with or obstruction of any investigation or audit related to—
(i) any offense described in paragraph (1) or in subsection (a); or
(ii) the use of funds received, directly or indirectly, from any Federal health care program (as defined in section 1320a–7b(f) of this title).
(3) Misdemeanor conviction relating to controlled substance
(4) License revocation or suspensionAny individual or entity—
(A) whose license to provide health care has been revoked or suspended by any State licensing authority, or who otherwise lost such a license or the right to apply for or renew such a license, for reasons bearing on the individual’s or entity’s professional competence, professional performance, or financial integrity, or
(B) who surrendered such a license while a formal disciplinary proceeding was pending before such an authority and the proceeding concerned the individual’s or entity’s professional competence, professional performance, or financial integrity.
(5) Exclusion or suspension under Federal or State health care programAny individual or entity which has been suspended or excluded from participation, or otherwise sanctioned, under—
(A) any Federal program, including programs of the Department of Defense or the Department of Veterans Affairs, involving the provision of health care, or
(B) a State health care program,
for reasons bearing on the individual’s or entity’s professional competence, professional performance, or financial integrity.
(6) Claims for excessive charges or unnecessary services and failure of certain organizations to furnish medically necessary servicesAny individual or entity that the Secretary determines—
(A) has submitted or caused to be submitted bills or requests for payment (where such bills or requests are based on charges or cost) under subchapter XVIII or a State health care program containing charges (or, in applicable cases, requests for payment of costs) for items or services furnished substantially in excess of such individual’s or entity’s usual charges (or, in applicable cases, substantially in excess of such individual’s or entity’s costs) for such items or services, unless the Secretary finds there is good cause for such bills or requests containing such charges or costs;
(B) has furnished or caused to be furnished items or services to patients (whether or not eligible for benefits under subchapter XVIII or under a State health care program) substantially in excess of the needs of such patients or of a quality which fails to meet professionally recognized standards of health care;
(C) is—
(i) a health maintenance organization (as defined in section 1396b(m) of this title) providing items and services under a State plan approved under subchapter XIX, or
(ii) an entity furnishing services under a waiver approved under section 1396n(b)(1) of this title,
and has failed substantially to provide medically necessary items and services that are required (under law or the contract with the State under subchapter XIX) to be provided to individuals covered under that plan or waiver, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals; or
(D) is an entity providing items and services as an eligible organization under a risk-sharing contract under section 1395mm of this title and has failed substantially to provide medically necessary items and services that are required (under law or such contract) to be provided to individuals covered under the risk-sharing contract, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals.
(7) Fraud, kickbacks, and other prohibited activities
(8) Entities controlled by a sanctioned individualAny entity with respect to which the Secretary determines that a person—
(A)
(i) who has a direct or indirect ownership or control interest of 5 percent or more in the entity or with an ownership or control interest (as defined in section 1320a–3(a)(3) of this title) in that entity,
(ii) who is an officer, director, agent, or managing employee (as defined in section 1320a–5(b) of this title) of that entity; or
(iii) who was described in clause (i) but is no longer so described because of a transfer of ownership or control interest, in anticipation of (or following) a conviction, assessment, or exclusion described in subparagraph (B) against the person, to an immediate family member (as defined in subsection (j)(1)) or a member of the household of the person (as defined in subsection (j)(2)) who continues to maintain an interest described in such clause—
is a person—
(B)
(i) who has been convicted of any offense described in subsection (a) or in paragraph (1), (2), or (3) of this subsection;
(ii) against whom a civil monetary penalty has been assessed under section 1320a–7a or 1320a–8 of this title; or
(iii) who has been excluded from participation under a program under subchapter XVIII or under a State health care program.
(9) Failure to disclose required information
(10) Failure to supply requested information on subcontractors and suppliersAny disclosing entity (as defined in section 1320a–3(a)(2) of this title) that fails to supply (within such period as may be specified by the Secretary in regulations) upon request specifically addressed to the entity by the Secretary or by the State agency administering or supervising the administration of a State health care program—
(A) full and complete information as to the ownership of a subcontractor (as defined by the Secretary in regulations) with whom the entity has had, during the previous 12 months, business transactions in an aggregate amount in excess of $25,000, or
(B) full and complete information as to any significant business transactions (as defined by the Secretary in regulations), occurring during the five-year period ending on the date of such request, between the entity and any wholly owned supplier or between the entity and any subcontractor.
(11) Failure to supply payment information
(12) Failure to grant immediate accessAny individual or entity that fails to grant immediate access, upon reasonable request (as defined by the Secretary in regulations) to any of the following:
(A) To the Secretary, or to the agency used by the Secretary, for the purpose specified in the first sentence of section 1395aa(a) of this title (relating to compliance with conditions of participation or payment).
(B) To the Secretary or the State agency, to perform the reviews and surveys required under State plans under paragraphs (26), (31), and (33) of section 1396a(a) of this title and under section 1396b(g) of this title.
(C) To the Inspector General of the Department of Health and Human Services, for the purpose of reviewing records, documents, and other data necessary to the performance of the statutory functions of the Inspector General.
(D) To a State medicaid fraud control unit (as defined in section 1396b(q) of this title), for the purpose of conducting activities described in that section.
(13) Failure to take corrective action
(14) Default on health education loan or scholarship obligations
(15) Individuals controlling a sanctioned entity
(A) Any individual—
(i) who has a direct or indirect ownership or control interest in a sanctioned entity and who knows or should know (as defined in section 1320a–7a(i)(6) 1
1 So in original. Probably should be section “1320a–7a(i)(7)”.
of this title) of the action constituting the basis for the conviction or exclusion described in subparagraph (B); or
(ii) who is an officer or managing employee (as defined in section 1320a–5(b) of this title) of such an entity.
(B) For purposes of subparagraph (A), the term “sanctioned entity” means an entity—
(i) that has been convicted of any offense described in subsection (a) or in paragraph (1), (2), or (3) of this subsection; or
(ii) that has been excluded from participation under a program under subchapter XVIII or under a State health care program.
(16) Making false statements or misrepresentation of material facts
(17) Knowingly misclassifying covered outpatient drugs
(c) Notice, effective date, and period of exclusion
(1) An exclusion under this section or under section 1320a–7a of this title shall be effective at such time and upon such reasonable notice to the public and to the individual or entity excluded as may be specified in regulations consistent with paragraph (2).
(2)
(A) Except as provided in subparagraph (B), such an exclusion shall be effective with respect to services furnished to an individual on or after the effective date of the exclusion.
(B) Unless the Secretary determines that the health and safety of individuals receiving services warrants the exclusion taking effect earlier, an exclusion shall not apply to payments made under subchapter XVIII or under a State health care program for—
(i) inpatient institutional services furnished to an individual who was admitted to such institution before the date of the exclusion, or
(ii) home health services and hospice care furnished to an individual under a plan of care established before the date of the exclusion,
until the passage of 30 days after the effective date of the exclusion.
(3)
(A) The Secretary shall specify, in the notice of exclusion under paragraph (1) and the written notice under section 1320a–7a of this title, the minimum period (or, in the case of an exclusion of an individual under subsection (b)(12) or in the case described in subparagraph (G), the period) of the exclusion.
(B) Subject to subparagraph (G), in the case of an exclusion under subsection (a), the minimum period of exclusion shall be not less than five years, except that, upon the request of the administrator of a Federal health care program (as defined in section 1320a–7b(f) of this title) who determines that the exclusion would impose a hardship on beneficiaries (as defined in section 1320a–7a(i)(5) of this title) of that program, the Secretary may, after consulting with the Inspector General of the Department of Health and Human Services, waive the exclusion under subsection (a)(1), (a)(3), or (a)(4) with respect to that program in the case of an individual or entity that is the sole community physician or sole source of essential specialized services in a community. The Secretary’s decision whether to waive the exclusion shall not be reviewable.
(C) In the case of an exclusion of an individual under subsection (b)(12), the period of the exclusion shall be equal to the sum of—
(i) the length of the period in which the individual failed to grant the immediate access described in that subsection, and
(ii) an additional period, not to exceed 90 days, set by the Secretary.
(D) Subject to subparagraph (G), in the case of an exclusion of an individual or entity under paragraph (1), (2), or (3) of subsection (b), the period of the exclusion shall be 3 years, unless the Secretary determines in accordance with published regulations that a shorter period is appropriate because of mitigating circumstances or that a longer period is appropriate because of aggravating circumstances.
(E) In the case of an exclusion of an individual or entity under subsection (b)(4) or (b)(5), the period of the exclusion shall not be less than the period during which the individual’s or entity’s license to provide health care is revoked, suspended, or surrendered, or the individual or the entity is excluded or suspended from a Federal or State health care program.
(F) In the case of an exclusion of an individual or entity under subsection (b)(6)(B), the period of the exclusion shall be not less than 1 year.
(G) In the case of an exclusion of an individual under subsection (a) based on a conviction occurring on or after August 5, 1997, if the individual has (before, on, or after August 5, 1997) been convicted—
(i) on one previous occasion of one or more offenses for which an exclusion may be effected under such subsection, the period of the exclusion shall be not less than 10 years, or
(ii) on 2 or more previous occasions of one or more offenses for which an exclusion may be effected under such subsection, the period of the exclusion shall be permanent.
(d) Notice to State agencies and exclusion under State health care programs
(1) Subject to paragraph (3), the Secretary shall exercise the authority under this section and section 1320a–7a of this title in a manner that results in an individual’s or entity’s exclusion from all the programs under subchapter XVIII and all the State health care programs in which the individual or entity may otherwise participate.
(2) The Secretary shall promptly notify each appropriate State agency administering or supervising the administration of each State health care program (and, in the case of an exclusion effected pursuant to subsection (a) and to which section 824(a)(5) of title 21 may apply, the Attorney General)—
(A) of the fact and circumstances of each exclusion effected against an individual or entity under this section or section 1320a–7a of this title, and
(B) of the period (described in paragraph (3)) for which the State agency is directed to exclude the individual or entity from participation in the State health care program.
(3)
(A) Except as provided in subparagraph (B), the period of the exclusion under a State health care program under paragraph (2) shall be the same as any period of exclusion under subchapter XVIII.
(B)
(i) The Secretary may waive an individual’s or entity’s exclusion under a State health care program under paragraph (2) if the Secretary receives and approves a request for the waiver with respect to the individual or entity from the State agency administering or supervising the administration of the program.
(ii) A State health care program may provide for a period of exclusion which is longer than the period of exclusion under subchapter XVIII.
(e) Notice to State licensing agenciesThe Secretary shall—
(1) promptly notify the appropriate State or local agency or authority having responsibility for the licensing or certification of an individual or entity excluded (or directed to be excluded) from participation under this section or section 1320a–7a of this title, of the fact and circumstances of the exclusion,
(2) request that appropriate investigations be made and sanctions invoked in accordance with applicable State law and policy, and
(3) request that the State or local agency or authority keep the Secretary and the Inspector General of the Department of Health and Human Services fully and currently informed with respect to any actions taken in response to the request.
(f) Notice, hearing, and judicial review
(1) Subject to paragraph (2), any individual or entity that is excluded (or directed to be excluded) from participation under this section is entitled to reasonable notice and opportunity for a hearing thereon by the Secretary to the same extent as is provided in section 405(b) of this title, and to judicial review of the Secretary’s final decision after such hearing as is provided in section 405(g) of this title, except that, in so applying such sections and section 405(l) of this title, any reference therein to the Commissioner of Social Security or the Social Security Administration shall be considered a reference to the Secretary or the Department of Health and Human Services, respectively.
(2) Unless the Secretary determines that the health or safety of individuals receiving services warrants the exclusion taking effect earlier, any individual or entity that is the subject of an adverse determination under subsection (b)(7) shall be entitled to a hearing by an administrative law judge (as provided under section 405(b) of this title) on the determination under subsection (b)(7) before any exclusion based upon the determination takes effect.
(3) The provisions of section 405(h) of this title shall apply with respect to this section and sections 1320a–7a, 1320a–8, and 1320c–5 of this title to the same extent as it is applicable with respect to subchapter II, except that, in so applying such section and section 405(l) of this title, any reference therein to the Commissioner of Social Security shall be considered a reference to the Secretary.
(4) The provisions of subsections (d) and (e) of section 405 of this title shall apply with respect to this section to the same extent as they are applicable with respect to subchapter II. The Secretary may delegate the authority granted by section 405(d) of this title (as made applicable to this section) to the Inspector General of the Department of Health and Human Services for purposes of any investigation under this section.
(g) Application for termination of exclusion
(1) An individual or entity excluded (or directed to be excluded) from participation under this section or section 1320a–7a of this title may apply to the Secretary, in the manner specified by the Secretary in regulations and at the end of the minimum period of exclusion provided under subsection (c)(3) and at such other times as the Secretary may provide, for termination of the exclusion effected under this section or section 1320a–7a of this title.
(2) The Secretary may terminate the exclusion if the Secretary determines, on the basis of the conduct of the applicant which occurred after the date of the notice of exclusion or which was unknown to the Secretary at the time of the exclusion, that—
(A) there is no basis under subsection (a) or (b) or section 1320a–7a(a) of this title for a continuation of the exclusion, and
(B) there are reasonable assurances that the types of actions which formed the basis for the original exclusion have not recurred and will not recur.
(3) The Secretary shall promptly notify each appropriate State agency administering or supervising the administration of each State health care program (and, in the case of an exclusion effected pursuant to subsection (a) and to which section 824(a)(5) of title 21 may apply, the Attorney General) of the fact and circumstances of each termination of exclusion made under this subsection.
(h) “State health care program” definedFor purposes of this section and sections 1320a–7a and 1320a–7b of this title, the term “State health care program” means—
(1) a State plan approved under subchapter XIX,
(2) any program receiving funds under subchapter V or from an allotment to a State under such subchapter,
(3) any program receiving funds under division A 2
2 See References in Text note below.
of subchapter XX or from an allotment to a State under such division, or
(4) a State child health plan approved under subchapter XXI.
(i) “Convicted” definedFor purposes of subsections (a) and (b), an individual or entity is considered to have been “convicted” of a criminal offense—
(1) when a judgment of conviction has been entered against the individual or entity by a Federal, State, or local court, regardless of whether there is an appeal pending or whether the judgment of conviction or other record relating to criminal conduct has been expunged;
(2) when there has been a finding of guilt against the individual or entity by a Federal, State, or local court;
(3) when a plea of guilty or nolo contendere by the individual or entity has been accepted by a Federal, State, or local court; or
(4) when the individual or entity has entered into participation in a first offender, deferred adjudication, or other arrangement or program where judgment of conviction has been withheld.
(j) Definition of immediate family member and member of householdFor purposes of subsection (b)(8)(A)(iii):
(1) The term “immediate family member” means, with respect to a person—
(A) the husband or wife of the person;
(B) the natural or adoptive parent, child, or sibling of the person;
(C) the stepparent, stepchild, stepbrother, or stepsister of the person;
(D) the father-, mother-, daughter-, son-, brother-, or sister-in-law of the person;
(E) the grandparent or grandchild of the person; and
(F) the spouse of a grandparent or grandchild of the person.
(2) The term “member of the household” means, with respect to any person, any individual sharing a common abode as part of a single family unit with the person, including domestic employees and others who live together as a family unit, but not including a roomer or boarder.
(Aug. 14, 1935, ch. 531, title XI, § 1128, as added Pub. L. 96–499, title IX, § 913(a), Dec. 5, 1980, 94 Stat. 2619; amended Pub. L. 97–35, title XXI, § 2105(b), title XXIII, § 2353(k), Aug. 13, 1981, 95 Stat. 791, 873; Pub. L. 98–369, div. B, title III, § 2333(a), (b), July 18, 1984, 98 Stat. 1089; Pub. L. 99–509, title IX, § 9317(c), Oct. 21, 1986, 100 Stat. 2008;

CITE AS: 42 USC 1320a-7

§ 1320a–7a. Civil monetary penalties
(a) Improperly filed claimsAny person (including an organization, agency, or other entity, but excluding a beneficiary, as defined in subsection (i)(5)) that—
(1) knowingly presents or causes to be presented to an officer, employee, or agent of the United States, or of any department or agency thereof, or of any State agency (as defined in subsection (i)(1)), a claim (as defined in subsection (i)(2)) that the Secretary determines—
(A) is for a medical or other item or service that the person knows or should know was not provided as claimed, including any person who engages in a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that the person knows or should know will result in a greater payment to the person than the code the person knows or should know is applicable to the item or service actually provided,
(B) is for a medical or other item or service and the person knows or should know the claim is false or fraudulent,
(C) is presented for a physician’s service (or an item or service incident to a physician’s service) by a person who knows or should know that the individual who furnished (or supervised the furnishing of) the service—
(i) was not licensed as a physician,
(ii) was licensed as a physician, but such license had been obtained through a misrepresentation of material fact (including cheating on an examination required for licensing), or
(iii) represented to the patient at the time the service was furnished that the physician was certified in a medical specialty by a medical specialty board when the individual was not so certified,
(D) is for a medical or other item or service furnished during a period in which the person was excluded from the Federal health care program (as defined in section 1320a–7b(f) of this title) under which the claim was made pursuant to Federal law.1
1 So in original. Probably should be “law, or”.
(E) is for a pattern of medical or other items or services that a person knows or should know are not medically necessary;
(2) knowingly presents or causes to be presented to any person a request for payment which is in violation of the terms of (A) an assignment under section 1395u(b)(3)(B)(ii) of this title, or (B) an agreement with a State agency (or other requirement of a State plan under subchapter XIX) not to charge a person for an item or service in excess of the amount permitted to be charged, or (C) an agreement to be a participating physician or supplier under section 1395u(h)(1) of this title, or (D) an agreement pursuant to section 1395cc(a)(1)(G) of this title;
(3) knowingly gives or causes to be given to any person, with respect to coverage under subchapter XVIII of inpatient hospital services subject to the provisions of section 1395ww of this title, information that he knows or should know is false or misleading, and that could reasonably be expected to influence the decision when to discharge such person or another individual from the hospital;
(4) in the case of a person who is not an organization, agency, or other entity, is excluded from participating in a program under subchapter XVIII or a State health care program in accordance with this subsection or under section 1320a–7 of this title and who, at the time of a violation of this subsection—
(A) retains a direct or indirect ownership or control interest in an entity that is participating in a program under subchapter XVIII or a State health care program, and who knows or should know of the action constituting the basis for the exclusion; or
(B) is an officer or managing employee (as defined in section 1320a–5(b) of this title) of such an entity;
(5) offers to or transfers remuneration to any individual eligible for benefits under subchapter XVIII of this chapter, or under a State health care program (as defined in section 1320a–7(h) of this title) that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, under subchapter XVIII, or a State health care program (as so defined);
(6) arranges or contracts (by employment or otherwise) with an individual or entity that the person knows or should know is excluded from participation in a Federal health care program (as defined in section 1320a–7b(f) of this title), for the provision of items or services for which payment may be made under such a program;
(7) commits an act described in paragraph (1) or (2) of section 1320a–7b(b) of this title;
(8)2
2 So in original. Two pars. (8) have been enacted.
knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim for payment for items and services furnished under a Federal health care program; or 3
3 So in original. The word “or” probably should not appear.
(9)4
4 So in original. Two pars. (9) have been enacted.
fails to grant timely access, upon reasonable request (as defined by the Secretary in regulations), to the Inspector General of the Department of Health and Human Services, for the purpose of audits, investigations, evaluations, or other statutory functions of the Inspector General of the Department of Health and Human Services;
(8)2 orders or prescribes a medical or other item or service during a period in which the person was excluded from a Federal health care program (as so defined), in the case where the person knows or should know that a claim for such medical or other item or service will be made under such a program;
(9)4 knowingly makes or causes to be made any false statement, omission, or misrepresentation of a material fact in any application, bid, or contract to participate or enroll as a provider of services or a supplier under a Federal health care program (as so defined), including Medicare Advantage organizations under part C of subchapter XVIII, prescription drug plan sponsors under part D of subchapter XVIII, medicaid managed care organizations under subchapter XIX, and entities that apply to participate as providers of services or suppliers in such managed care organizations and such plans; 5
5 So in original. Probably should be followed by “or”.
(10) knows of an overpayment (as defined in paragraph (4) of section 1320a–7k(d) of this title) and does not report and return the overpayment in accordance with such section;
shall be subject, in addition to any other penalties that may be prescribed by law, to a civil money penalty of not more than $20,000 for each item or service (or, in cases under paragraph (3), $30,000 for each individual with respect to whom false or misleading information was given; in cases under paragraph (4), $20,000 for each day the prohibited relationship occurs; in cases under paragraph (7), $100,000 for each such act,6
6 So in original. The comma probably should be a semicolon.
in cases under paragraph (8),7
7 So in original. Probably is a reference to the first paragraph (8).
$100,000 for each false record or statement,6 or 3 in cases under paragraph (9),8
8 So in original. Probably is a reference to the first paragraph (9).
$15,000 for each day of the failure described in such paragraph); 9
9 So in original. Probably should be “paragraph;”.
or in cases under paragraph (9),10
10 So in original. Probably is a reference to the second paragraph (9).
$100,000 for each false statement or misrepresentation of a material fact). In addition, such a person shall be subject to an assessment of not more than 3 times the amount claimed for each such item or service in lieu of damages sustained by the United States or a State agency because of such claim (or, in cases under paragraph (7), damages of not more than 3 times the total amount of remuneration offered, paid, solicited, or received, without regard to whether a portion of such remuneration was offered, paid, solicited, or received for a lawful purpose; or in cases under paragraph (9), an assessment of not more than 3 times the total amount claimed for each item or service for which payment was made based upon the application containing the false statement or misrepresentation of a material fact). In addition the Secretary may make a determination in the same proceeding to exclude the person from participation in the Federal health care programs (as defined in section 1320a–7b(f)(1) of this title) and to direct the appropriate State agency to exclude the person from participation in any State health care program.
(b) Payments to induce reduction or limitation of services
(1) If a hospital or a critical access hospital knowingly makes a payment, directly or indirectly, to a physician as an inducement to reduce or limit medically necessary services provided with respect to individuals who—
(A) are entitled to benefits under part A or part B of subchapter XVIII or to medical assistance under a State plan approved under subchapter XIX, and
(B) are under the direct care of the physician,
the hospital or a critical access hospital shall be subject, in addition to any other penalties that may be prescribed by law, to a civil money penalty of not more than $5,000 for each such individual with respect to whom the payment is made.
(2) Any physician who knowingly accepts receipt of a payment described in paragraph (1) shall be subject, in addition to any other penalties that may be prescribed by law, to a civil money penalty of not more than $5,000 for each individual described in such paragraph with respect to whom the payment is made.
(3)
(A) Any physician who executes a document described in subparagraph (B) with respect to an individual knowing that all of the requirements referred to in such subparagraph are not met with respect to the individual shall be subject to a civil monetary penalty of not more than the greater of—
(i) $10,000, or
(ii) three times the amount of the payments under subchapter XVIII for home health services which are made pursuant to such certification.
(B) A document described in this subparagraph is any document that certifies, for purposes of subchapter XVIII, that an individual meets the requirements of section 1395f(a)(2)(C) or 1395n(a)(2)(A) of this title in the case of home health services furnished to the individual.
(c) Initiation of proceeding; authorization by Attorney General, notice, etc., estoppel, failure to comply with order or procedure
(1) The Secretary may initiate a proceeding to determine whether to impose a civil money penalty, assessment, or exclusion under subsection (a) or (b) only as authorized by the Attorney General pursuant to procedures agreed upon by them. The Secretary may not initiate an action under this section with respect to any claim, request for payment, or other occurrence described in this section later than six years after the date the claim was presented, the request for payment was made, or the occurrence took place. The Secretary may initiate an action under this section by serving notice of the action in any manner authorized by Rule 4 of the Federal Rules of Civil Procedure.
(2) The Secretary shall not make a determination adverse to any person under subsection (a) or (b) until the person has been given written notice and an opportunity for the determination to be made on the record after a hearing at which the person is entitled to be represented by counsel, to present witnesses, and to cross-examine witnesses against the person.
(3) In a proceeding under subsection (a) or (b) which—
(A) is against a person who has been convicted (whether upon a verdict after trial or upon a plea of guilty or nolo contendere) of a Federal crime charging fraud or false statements, and
(B) involves the same transaction as in the criminal action,
the person is estopped from denying the essential elements of the criminal offense.
(4) The official conducting a hearing under this section may sanction a person, including any party or attorney, for failing to comply with an order or procedure, failing to defend an action, or other misconduct as would interfere with the speedy, orderly, or fair conduct of the hearing. Such sanction shall reasonably relate to the severity and nature of the failure or misconduct. Such sanction may include—
(A) in the case of refusal to provide or permit discovery, drawing negative factual inferences or treating such refusal as an admission by deeming the matter, or certain facts, to be established,
(B) prohibiting a party from introducing certain evidence or otherwise supporting a particular claim or defense,
(C) striking pleadings, in whole or in part,
(D) staying the proceedings,
(E) dismissal of the action,
(F) entering a default judgment,
(G) ordering the party or attorney to pay attorneys’ fees and other costs caused by the failure or misconduct, and
(H) refusing to consider any motion or other action which is not filed in a timely manner.
(d) Amount or scope of penalty, assessment, or exclusionIn determining the amount or scope of any penalty, assessment, or exclusion imposed pursuant to subsection (a) or (b), the Secretary shall take into account—
(1) the nature of claims and the circumstances under which they were presented,
(2) the degree of culpability, history of prior offenses, and financial condition of the person presenting the claims, and
(3) such other matters as justice may require.
(e) Review by courts of appeals
(f) Compromise of penalties and assessments; recovery; use of funds recoveredCivil money penalties and assessments imposed under this section may be compromised by the Secretary and may be recovered in a civil action in the name of the United States brought in United States district court for the district where the claim or specified claim (as defined in subsection (r)) was presented, or where the claimant (or, with respect to a person described in subsection (o), the person) resides, as determined by the Secretary. Amounts recovered under this section shall be paid to the Secretary and disposed of as follows:
(1)
(A) In the case of amounts recovered arising out of a claim under subchapter XIX, there shall be paid to the State agency an amount bearing the same proportion to the total amount recovered as the State’s share of the amount paid by the State agency for such claim bears to the total amount paid for such claim.
(B) In the case of amounts recovered arising out of a claim under an allotment to a State under subchapter V, there shall be paid to the State agency an amount equal to three-sevenths of the amount recovered.
(2) Such portion of the amounts recovered as is determined to have been paid out of the trust funds under sections 1395i and 1395t of this title shall be repaid to such trust funds.
(3) With respect to amounts recovered arising out of a claim under a Federal health care program (as defined in section 1320a–7b(f) of this title), the portion of such amounts as is determined to have been paid by the program shall be repaid to the program, and the portion of such amounts attributable to the amounts recovered under this section by reason of the amendments made by the Health Insurance Portability and Accountability Act of 1996 (as estimated by the Secretary) shall be deposited into the Federal Hospital Insurance Trust Fund pursuant to
(4) The remainder of the amounts recovered shall be deposited as miscellaneous receipts of the Treasury of the United States.
The amount of such penalty or assessment, when finally determined, or the amount agreed upon in compromise, may be deducted from any sum then or later owing by the United States or a State agency (or, in the case of a penalty or assessment under subsection (o), by a specified State agency (as defined in subsection (q)(6)), to the person against whom the penalty or assessment has been assessed.
(g) Finality of determination respecting penalty, assessment, or exclusion
(h) Notification of appropriate entities of finality of determination
(i) DefinitionsFor the purposes of this section:
(1) The term “State agency” means the agency established or designated to administer or supervise the administration of the State plan under subchapter XIX of this chapter or designated to administer the State’s program under subchapter V or division A 12
12 See References in Text note below.
of subchapter XX of this chapter.
(2) The term “claim” means an application for payments for items and services under a Federal health care program (as defined in section 1320a–7b(f) of this title).
(3) The term “item or service” includes (A) any particular item, device, medical supply, or service claimed to have been provided to a patient and listed in an itemized claim for payment, and (B) in the case of a claim based on costs, any entry in the cost report, books of account or other documents supporting such claim.
(4) The term “agency of the United States” includes any contractor acting as a fiscal intermediary, carrier, or fiscal agent or any other claims processing agent for a Federal health care program (as so defined).
(5) The term “beneficiary” means an individual who is eligible to receive items or services for which payment may be made under a Federal health care program (as so defined) but does not include a provider, supplier, or practitioner.
(6) The term “remuneration” includes the waiver of coinsurance and deductible amounts (or any part thereof), and transfers of items or services for free or for other than fair market value. The term “remuneration” does not include—
(A) the waiver of coinsurance and deductible amounts by a person, if—
(i) the waiver is not offered as part of any advertisement or solicitation;
(ii) the person does not routinely waive coinsurance or deductible amounts; and
(iii) the person—(I) waives the coinsurance and deductible amounts after determining in good faith that the individual is in financial need; or(II) fails to collect coinsurance or deductible amounts after making reasonable collection efforts;
(B) subject to subsection (n), any permissible practice described in any subparagraph of section 1320a–7b(b)(3) of this title or in regulations issued by the Secretary;
(C) differentials in coinsurance and deductible amounts as part of a benefit plan design as long as the differentials have been disclosed in writing to all beneficiaries, third party payers, and providers, to whom claims are presented and as long as the differentials meet the standards as defined in regulations promulgated by the Secretary not later than 180 days after August 21, 1996;
(D) incentives given to individuals to promote the delivery of preventive care as determined by the Secretary in regulations so promulgated;
(E) a reduction in the copayment amount for covered OPD services under section 1395l(t)(5)(B) 12 of this title; or 3
(F) any other remuneration which promotes access to care and poses a low risk of harm to patients and Federal health care programs (as defined in section 1320a–7b(f) of this title and designated by the Secretary under regulations);
(G) the offer or transfer of items or services for free or less than fair market value by a person, if—
(i) the items or services consist of coupons, rebates, or other rewards from a retailer;
(ii) the items or services are offered or transferred on equal terms available to the general public, regardless of health insurance status; and
(iii) the offer or transfer of the items or services is not tied to the provision of other items or services reimbursed in whole or in part by the program under subchapter XVIII or a State health care program (as defined in section 1320a–7(h) of this title);
(H) the offer or transfer of items or services for free or less than fair market value by a person, if—
(i) the items or services are not offered as part of any advertisement or solicitation;
(ii) the items or services are not tied to the provision of other services reimbursed in whole or in part by the program under subchapter XVIII or a State health care program (as so defined);
(iii) there is a reasonable connection between the items or services and the medical care of the individual; and
(iv) the person provides the items or services after determining in good faith that the individual is in financial need;
(I) effective on a date specified by the Secretary (but not earlier than January 1, 2011), the waiver by a PDP sponsor of a prescription drug plan under part D of subchapter XVIII or an MA organization offering an MA–PD plan under part C of such subchapter of any copayment for the first fill of a covered part D drug (as defined in section 1395w–102(e) of this title) that is a generic drug for individuals enrolled in the prescription drug plan or MA–PD plan, respectively; or
(J) the provision of telehealth technologies (as defined by the Secretary) on or after January 1, 2019, by a provider of services or a renal dialysis facility (as such terms are defined for purposes of subchapter XVIII) to an individual with end stage renal disease who is receiving home dialysis for which payment is being made under part B of such subchapter, if—
(i) the telehealth technologies are not offered as part of any advertisement or solicitation;
(ii) the telehealth technologies are provided for the purpose of furnishing telehealth services related to the individual’s end stage renal disease; and
(iii) the provision of the telehealth technologies meets any other requirements set forth in regulations promulgated by the Secretary.
(7) The term “should know” means that a person, with respect to information—
(A) acts in deliberate ignorance of the truth or falsity of the information; or
(B) acts in reckless disregard of the truth or falsity of the information,
and no proof of specific intent to defraud is required.
(j) Subpoenas
(1) The provisions of subsections (d) and (e) of section 405 of this title shall apply with respect to this section to the same extent as they are applicable with respect to subchapter II. The Secretary may delegate the authority granted by section 405(d) of this title (as made applicable to this section) to the Inspector General of the Department of Health and Human Services for purposes of any investigation under this section.
(2) The Secretary may delegate authority granted under this section and under section 1320a–7 of this title to the Inspector General of the Department of Health and Human Services.
(k) Injunctions
(l) Liability of principal for acts of agent
(m) Claims within jurisdiction of other departments or agencies
(1) For purposes of this section, with respect to a Federal health care program not contained in this chapter, references to the Secretary in this section shall be deemed to be references to the Secretary or Administrator of the department or agency with jurisdiction over such program and references to the Inspector General of the Department of Health and Human Services in this section shall be deemed to be references to the Inspector General of the applicable department or agency.
(2)
(A) The Secretary and Administrator of the departments and agencies referred to in paragraph (1) may include in any action pursuant to this section, claims within the jurisdiction of other Federal departments or agencies as long as the following conditions are satisfied:
(i) The case involves primarily claims submitted to the Federal health care programs of the department or agency initiating the action.
(ii) The Secretary or Administrator of the department or agency initiating the action gives notice and an opportunity to participate in the investigation to the Inspector General of the department or agency with primary jurisdiction over the Federal health care programs to which the claims were submitted.
(B) If the conditions specified in subparagraph (A) are fulfilled, the Inspector General of the department or agency initiating the action is authorized to exercise all powers granted under chapter 4 of title 5 with respect to the claims submitted to the other departments or agencies to the same manner and extent as provided in that Act with respect to claims submitted to such departments or agencies.
(n) Safe harbor for payment of medigap premiums
(1) Subparagraph (B) of subsection (i)(6) shall not apply to a practice described in paragraph (2) unless—
(A) the Secretary, through the Inspector General of the Department of Health and Human Services, promulgates a rule authorizing such a practice as an exception to remuneration; and
(B) the remuneration is offered or transferred by a person under such rule during the 2-year period beginning on the date the rule is first promulgated.
(2) A practice described in this paragraph is a practice under which a health care provider or facility pays, in whole or in part, premiums for medicare supplemental policies for individuals entitled to benefits under part A of subchapter XVIII pursuant to section 426–1 of this title.
(o) Penalties for violations of grants, contracts, and other agreementsAny person (including an organization, agency, or other entity, but excluding a program beneficiary, as defined in subsection (q)(4)) that, with respect to a grant, contract, or other agreement for which the Secretary provides funding—
(1) knowingly presents or causes to be presented a specified claim (as defined in subsection (r)) under such grant, contract, or other agreement that the person knows or should know is false or fraudulent;
(2) knowingly makes, uses, or causes to be made or used any false statement, omission, or misrepresentation of a material fact in any application, proposal, bid, progress report, or other document that is required to be submitted in order to directly or indirectly receive or retain funds provided in whole or in part by such Secretary pursuant to such grant, contract, or other agreement;
(3) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent specified claim under such grant, contract, or other agreement;
(4) knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation (as defined in subsection (s)) to pay or transmit funds or property to such Secretary with respect to such grant, contract, or other agreement, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit funds or property to such Secretary with respect to such grant, contract, or other agreement; or
(5) fails to grant timely access, upon reasonable request (as defined by such Secretary in regulations), to the Inspector General of the Department, for the purpose of audits, investigations, evaluations, or other statutory functions of such Inspector General in matters involving such grants, contracts, or other agreements;
shall be subject, in addition to any other penalties that may be prescribed by law, to a civil money penalty in cases under paragraph (1), of not more than $10,000 for each specified claim; in cases under paragraph (2), not more than $50,000 for each false statement, omission, or misrepresentation of a material fact; in cases under paragraph (3), not more than $50,000 for each false record or statement; in cases under paragraph (4), not more than $50,000 for each false record or statement or $10,000 for each day that the person knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay; or in cases under paragraph (5), not more than $15,000 for each day of the failure described in such paragraph. In addition, in cases under paragraphs (1) and (3), such a person shall be subject to an assessment of not more than 3 times the amount claimed in the specified claim described in such paragraph in lieu of damages sustained by the United States or a specified State agency because of such specified claim, and in cases under paragraphs (2) and (4), such a person shall be subject to an assessment of not more than 3 times the total amount of the funds described in paragraph (2) or (4), respectively (or, in the case of an obligation to transmit property to the Secretary described in paragraph (4), of the value of the property described in such paragraph) in lieu of damages sustained by the United States or a specified State agency because of such case. In addition, the Secretary may make a determination in the same proceeding to exclude the person from participation in the Federal health care programs (as defined in section 1320a–7b(f)(1) of this title) and to direct the appropriate State agency to exclude the person from participation in any State health care program.
(p) Applicability of rules to penalties or assessments for violations of grants, contracts, and other agreements
(q) Definitions of terms used in subsections (o) and (p)For purposes of this subsection and subsections (o) and (p):
(1) The term “Department” means the Department of Health and Human Services.
(2) The term “material” means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.
(3) The term “other agreement” includes a cooperative agreement, scholarship, fellowship, loan, subsidy, payment for a specified use, donation agreement, award, or subaward (regardless of whether one or more of the persons entering into the agreement is a contractor or subcontractor).
(4) The term “program beneficiary” means, in the case of a grant, contract, or other agreement designed to accomplish the objective of awarding or otherwise furnishing benefits or assistance to individuals and for which the Secretary provides funding, an individual who applies for, or who receives, such benefits or assistance from such grant, contract, or other agreement. Such term does not include, with respect to such grant, contract, or other agreement, an officer, employee, or agent of a person or entity that receives such grant or that enters into such contract or other agreement.
(5) The term “recipient” includes a subrecipient or subcontractor.
(6) The term “specified State agency” means an agency of a State government established or designated to administer or supervise the administration of a grant, contract, or other agreement funded in whole or in part by the Secretary.
(r) Definition of “specified claim”For purposes of this section, the term “specified claim” means any application, request, or demand under a grant, contract, or other agreement for money or property, whether or not the United States or a specified State agency has title to the money or property, that is not a claim (as defined in subsection (i)(2)) and that—
(1) is presented or caused to be presented to an officer, employee, or agent of the Department or agency thereof, or of any specified State agency; or
(2) is made to a contractor, grantee, or any other recipient if the money or property is to be spent or used on the Department’s behalf or to advance a Department program or interest, and if the Department—
(A) provides or has provided any portion of the money or property requested or demanded; or
(B) will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded.
(s) Definition of “obligation”
(Aug. 14, 1935, ch. 531, title XI, § 1128A, as added Pub. L. 97–35, title XXI, § 2105(a), Aug. 13, 1981, 95 Stat. 789; amended Pub. L. 97–248, title I, § 137(b)(26), Sept. 3, 1982, 96 Stat. 380; Pub. L. 98–369, div. B, title III, §§ 2306(f)(1), 2354(a)(3), July 18, 1984, 98 Stat. 1073, 1100; Pub. L. 99–509, title IX, §§ 9313(c)(1), 9317(a), (b), Oct. 21, 1986, 100 Stat. 2003, 2008; Pub. L. 100–93, § 3, Aug. 18, 1987, 101 Stat. 686; Pub. L. 100–203, title IV, §§ 4039(h)(1), 4118(e)(1), (6)–(10), Dec. 22, 1987, 101 Stat. 1330–155, as amended Pub. L. 100–360, title IV, § 411(e)(3), (k)(10)(B)(ii), (D), July 1, 1988, 102 Stat. 775, 794, 795; Pub. L. 100–360, title II, § 202(c)(2), July 1, 1988, 102 Stat. 715; Pub. L. 100–485, title VI, § 608(d)(26)(H)–(K)(i), Oct. 13, 1988, 102 Stat. 2422; Pub. L. 101–234, title II, § 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L. 101–239, title VI, § 6003(g)(3)(D)(i), Dec. 19, 1989, 103 Stat. 2153; Pub. L. 101–508, title IV, §§ 4204(a)(3), 4207(h), formerly 4027(h), 4731(b)(1), 4753, Nov. 5, 1990, 104 Stat. 1388–109, 1388–123, 1388–195, 1388–208, renumbered § 4207(h), Pub. L. 103–432, title I, § 160(d)(4), Oct. 31, 1994, 108 Stat. 4444; Pub. L. 104–191, title II, §§ 231(a)–(e), (h), 232(a), Aug. 21, 1996, 110 Stat. 2012–2015; Pub. L. 105–33, title IV, §§ 4201(c)(1), 4304(a), (b), 4331(e), 4523(c), Aug. 5, 1997, 111 Stat. 373, 383, 396, 449; Pub. L. 105–277, div. J, title V, § 5201(a), (b)(1), Oct. 21, 1998, 112 Stat. 2681–916; Pub. L. 111–148, title VI, §§ 6402(d)(2), 6408(a), 6703(d)(3)(B), Mar. 23, 2010, 124 Stat. 757, 770, 804; Pub. L. 114–10, title V, § 512(a)(1), Apr. 16, 2015, 129 Stat. 170; Pub. L. 114–255, div. A, title V, § 5003, Dec. 13, 2016, 130 Stat. 1188; Pub. L. 115–123, div. E, title III, § 50302(c), title IV, § 50412(a)(1), Feb. 9, 2018, 132 Stat. 191, 220; Pub. L. 117–286, § 4(b)(77), Dec. 27, 2022, 136 Stat. 4351.)

CITE AS: 42 USC 1320a-7a

§ 1320a–7b. Criminal penalties for acts involving Federal health care programs
(a) Making or causing to be made false statements or representationsWhoever—
(1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program (as defined in subsection (f)),
(2) at any time knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment,
(3) having knowledge of the occurrence of any event affecting (A) his initial or continued right to any such benefit or payment, or (B) the initial or continued right to any such benefit or payment of any other individual in whose behalf he has applied for or is receiving such benefit or payment, conceals or fails to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized,
(4) having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and willfully converts such benefit or payment or any part thereof to a use other than for the use and benefit of such other person,
(5) presents or causes to be presented a claim for a physician’s service for which payment may be made under a Federal health care program and knows that the individual who furnished the service was not licensed as a physician, or
(6) for a fee knowingly and willfully counsels or assists an individual to dispose of assets (including by any transfer in trust) in order for the individual to become eligible for medical assistance under a State plan under subchapter XIX, if disposing of the assets results in the imposition of a period of ineligibility for such assistance under section 1396p(c) of this title,
shall (i) in the case of such a statement, representation, concealment, failure, or conversion by any person in connection with the furnishing (by that person) of items or services for which payment is or may be made under the program, be guilty of a felony and upon conviction thereof fined not more than $100,000 or imprisoned for not more than 10 years or both, or (ii) in the case of such a statement, representation, concealment, failure, conversion, or provision of counsel or assistance by any other person, be guilty of a misdemeanor and upon conviction thereof fined not more than $20,000 or imprisoned for not more than one year, or both. In addition, in any case where an individual who is otherwise eligible for assistance under a Federal health care program is convicted of an offense under the preceding provisions of this subsection, the administrator of such program may at its option (notwithstanding any other provision of such program) limit, restrict, or suspend the eligibility of that individual for such period (not exceeding one year) as it deems appropriate; but the imposition of a limitation, restriction, or suspension with respect to the eligibility of any individual under this sentence shall not affect the eligibility of any other person for assistance under the plan, regardless of the relationship between that individual and such other person.
(b) Illegal remunerations
(1) Whoever knowingly and willfully solicits or receives any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind—
(A) in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or
(B) in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program,
shall be guilty of a felony and upon conviction thereof, shall be fined not more than $100,000 or imprisoned for not more than 10 years, or both.
(2) Whoever knowingly and willfully offers or pays any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person—
(A) to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or
(B) to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program,
shall be guilty of a felony and upon conviction thereof, shall be fined not more than $100,000 or imprisoned for not more than 10 years, or both.
(3) Paragraphs (1) and (2) shall not apply to—
(A) a discount or other reduction in price obtained by a provider of services or other entity under a Federal health care program if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider or entity under a Federal health care program;
(B) any amount paid by an employer to an employee (who has a bona fide employment relationship with such employer) for employment in the provision of covered items or services;
(C) any amount paid by a vendor of goods or services to a person authorized to act as a purchasing agent for a group of individuals or entities who are furnishing services reimbursed under a Federal health care program if—
(i) the person has a written contract, with each such individual or entity, which specifies the amount to be paid the person, which amount may be a fixed amount or a fixed percentage of the value of the purchases made by each such individual or entity under the contract, and
(ii) in the case of an entity that is a provider of services (as defined in section 1395x(u) of this title), the person discloses (in such form and manner as the Secretary requires) to the entity and, upon request, to the Secretary the amount received from each such vendor with respect to purchases made by or on behalf of the entity;
(D) a waiver of any coinsurance under part B of subchapter XVIII by a Federally qualified health care center with respect to an individual who qualifies for subsidized services under a provision of the Public Health Service Act [42 U.S.C. 201 et seq.];
(E) any payment practice specified by the Secretary in regulations promulgated pursuant to section 14(a) of the Medicare and Medicaid Patient and Program Protection Act of 1987 or in regulations under section 1395w–104(e)(6) 1
1 See References in Text note below.
of this title;
(F) any remuneration between an organization and an individual or entity providing items or services, or a combination thereof, pursuant to a written agreement between the organization and the individual or entity if the organization is an eligible organization under section 1395mm of this title or if the written agreement, through a risk-sharing arrangement, places the individual or entity at substantial financial risk for the cost or utilization of the items or services, or a combination thereof, which the individual or entity is obligated to provide;
(G) the waiver or reduction by pharmacies (including pharmacies of the Indian Health Service, Indian tribes, tribal organizations, and urban Indian organizations) of any cost-sharing imposed under part D of subchapter XVIII, if the conditions described in clauses (i) through (iii) of section 1320a–7a(i)(6)(A) of this title are met with respect to the waiver or reduction (except that, in the case of such a waiver or reduction on behalf of a subsidy eligible individual (as defined in section 1395w–114(a)(3) of this title), section 1320a–7a(i)(6)(A) of this title shall be applied without regard to clauses (ii) and (iii) of that section);
(H) any remuneration between a federally qualified health center (or an entity controlled by such a health center) and an MA organization pursuant to a written agreement described in section 1395w–23(a)(4) of this title;
(I) any remuneration between a health center entity described under clause (i) or (ii) of section 1396d(l)(2)(B) of this title and any individual or entity providing goods, items, services, donations, loans, or a combination thereof, to such health center entity pursuant to a contract, lease, grant, loan, or other agreement, if such agreement contributes to the ability of the health center entity to maintain or increase the availability, or enhance the quality, of services provided to a medically underserved population served by the health center entity;
(J) a discount in the price of an applicable drug (as defined in paragraph (2) of section 1395w–114a(g) of this title) of a manufacturer that is furnished to an applicable beneficiary (as defined in paragraph (1) of such section) under the Medicare coverage gap discount program under section 1395w–114a of this title;
(K) an incentive payment made to a Medicare fee-for-service beneficiary by an ACO under an ACO Beneficiary Incentive Program established under subsection (m) of section 1395jjj of this title, if the payment is made in accordance with the requirements of such subsection and meets such other conditions as the Secretary may establish; and
(L) a bona fide mental health or behavioral health improvement or maintenance program, if—
(i) such program—(I) consists of counseling, mental health services, a suicide prevention program, or a substance use disorder prevention and treatment program;(II) is made available to a physician or other clinician for the primary purpose of preventing suicide, improving mental health and resiliency, or providing training in appropriate strategies to promote the mental health and resiliency of such physician or other clinician;(III) is set out in a written policy, approved in advance of the operation of the program by the governing body of the entity providing such program (and which shall be updated accordingly in advance to substantial changes to the operation of such program), that includes—(aa) a description of the span and duration of the program;(bb) a description of the evidence-based support for the design of the program;(cc) the estimated cost of the program;(dd) the personnel (including the qualifications of such personnel) implementing the program; and(ee) the method by which such entity will evaluate the use and success of the program;(IV) is offered by an entity described in clause (ii) with a formal medical staff to all physicians and other clinicians who practice in the geographic area served by such entity, including physicians who hold bona fide appointments to the medical staff of such entity or otherwise have clinical privileges at such entity;(V) is offered to all such physicians and clinicians on the same terms and conditions and without regard to the volume or value of referrals or other business generated by a physician or clinician for such entity;(VI) is evidence-based and conducted by a qualified health professional; and(VII) meets such other requirements the Secretary may impose by regulation as needed to protect against program or patient abuse;
(ii) such entity is—(I) a hospital;(II) an ambulatory surgical center;(III) a community health center;(IV) a rural emergency hospital;(V) a skilled nursing facility; or(VI) any similar entity, as determined by the Secretary; and
(iii) neither the provision of such program, nor the value of such program, are contingent upon the number or value of referrals made by a physician or other clinician to such entity or the amount or value of other business generated by such physician for the entity.
(4) Whoever without lawful authority knowingly and willfully purchases, sells or distributes, or arranges for the purchase, sale, or distribution of a beneficiary identification number or unique health identifier for a health care provider under subchapter XVIII, subchapter XIX, or subchapter XXI shall be imprisoned for not more than 10 years or fined not more than $500,000 ($1,000,000 in the case of a corporation), or both.
(c) False statements or representations with respect to condition or operation of institutions
(d) Illegal patient admittance and retention practicesWhoever knowingly and willfully—
(1) charges, for any service provided to a patient under a State plan approved under subchapter XIX, money or other consideration at a rate in excess of the rates established by the State (or, in the case of services provided to an individual enrolled with a medicaid managed care organization under subchapter XIX under a contract under section 1396b(m) of this title or under a contractual, referral, or other arrangement under such contract, at a rate in excess of the rate permitted under such contract), or
(2) charges, solicits, accepts, or receives, in addition to any amount otherwise required to be paid under a State plan approved under subchapter XIX, any gift, money, donation, or other consideration (other than a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to the patient)—
(A) as a precondition of admitting a patient to a hospital, nursing facility, or intermediate care facility for the mentally retarded, or
(B) as a requirement for the patient’s continued stay in such a facility,
when the cost of the services provided therein to the patient is paid for (in whole or in part) under the State plan,
shall be guilty of a felony and upon conviction thereof shall be fined not more than $100,000 or imprisoned for not more than 10 years, or both.
(e) Violation of assignment terms
(f) “Federal health care program” definedFor purposes of this section, the term “Federal health care program” means—
(1) any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government (other than the health insurance program under chapter 89 of title 5); or
(2) any State health care program, as defined in section 1320a–7(h) of this title.
(g) Liability under subchapter III of chapter 37 of title 31
(h) Actual knowledge or specific intent not required
(Aug. 14, 1935, ch. 531, title XI, § 1128B, formerly title XVIII, § 1877(d), and title XIX, § 1909, as added and amended Pub. L. 92–603, title II, §§ 242(c), 278(b)(9), Oct. 30, 1972, 86 Stat. 1419, 1454; Pub. L. 95–142, § 4(a), (b), Oct. 25, 1977, 91 Stat. 1179, 1181; Pub. L. 96–499, title IX, § 917, Dec. 5, 1980, 94 Stat. 2625; Pub. L. 98–369, div. B, title III, § 2306(f)(2), July 18, 1984, 98 Stat. 1073; renumbered title XI, § 1128B, and amended Pub. L. 100–93, §§ 4(a)–(d), 14(b), Aug. 18, 1987, 101 Stat. 688, 689, 697; Pub. L. 100–203, title IV, §§ 4039(a), 4211(h)(7), Dec. 22, 1987, 101 Stat. 1330–81, 1330–206; Pub. L. 100–360, title IV, § 411(a)(3)(A), (B)(i), July 1, 1988, 102 Stat. 768; Pub. L. 101–239, title VI, § 6003(g)(3)(D)(ii), Dec. 19, 1989, 103 Stat. 2153; Pub. L. 101–508, title IV, §§ 4161(a)(4), 4164(b)(2), Nov. 5, 1990, 104 Stat. 1388–94, 1388–102; Pub. L. 103–432, title I, § 133(a)(2), Oct. 31, 1994, 108 Stat. 4421; Pub. L. 104–191, title II, §§ 204(a), 216(a), 217, Aug. 21, 1996, 110 Stat. 1999, 2007, 2008; Pub. L. 105–33, title IV, §§ 4201(c)(1), 4704(b), 4734, Aug. 5, 1997, 111 Stat. 373, 498, 522; Pub. L. 108–173, title I, § 101(e)(2), (8)(A), title II, § 237(d), title IV, § 431(a), Dec. 8, 2003, 117 Stat. 2150, 2152, 2213, 2287; Pub. L. 111–148, title III, § 3301(d)(1), title VI, § 6402(f), Mar. 23, 2010, 124 Stat. 468, 759; Pub. L. 114–115, § 8, Dec. 28, 2015, 129 Stat. 3134; Pub. L. 115–123, div. E, title III, § 50341(b), title IV, § 50412(a)(2), (b), Feb. 9, 2018, 132 Stat. 208, 220;

CITE AS: 42 USC 1320a-7b

§ 1320a–7c. Fraud and abuse control program
(a) Establishment of program
(1) In general
Not later than January 1, 1997, the Secretary, acting through the Office of the Inspector General of the Department of Health and Human Services, and the Attorney General shall establish a program—
(A) to coordinate Federal, State, and local law enforcement programs to control fraud and abuse with respect to health plans,
(B) to conduct investigations, audits, evaluations, and inspections relating to the delivery of and payment for health care in the United States,
(C) to facilitate the enforcement of the provisions of sections 1320a–7, 1320a–7a, and 1320a–7b of this title and other statutes applicable to health care fraud and abuse, and
(D) to provide for the modification and establishment of safe harbors and to issue advisory opinions and special fraud alerts pursuant to section 1320a–7d of this title.
(2) Coordination with health plans
(3) Guidelines
(A) In general
(B) Information guidelines
(i) In general
(ii) Confidentiality
(iii) Qualified immunity for providing information
(4) Ensuring access to documentation
(5) Authority of Inspector General
(6) Public-private partnership for waste, fraud, and abuse detection
(A) In general
(B) Contract with trusted third party
(C) Duties of partnership
The partnership shall—
(i) provide technical and operational support to facilitate data sharing between partners in the partnership;
(ii) analyze data so shared to identify fraudulent and aberrant billing patterns;
(iii) conduct aggregate analyses of health care data so shared across Federal, State, and private health plans for purposes of detecting fraud, waste, and abuse schemes;
(iv) identify outlier trends and potential vulnerabilities of partners in the partnership with respect to such schemes;
(v) refer specific cases of potential unlawful conduct to appropriate governmental entities;
(vi) convene, not less than annually, meetings with partners in the partnership for purposes of providing updates on the partnership’s work and facilitating information sharing between the partners;
(vii) enter into data sharing and data use agreements with partners in the partnership in such a manner so as to ensure the partnership has access to data necessary to identify waste, fraud, and abuse while maintaining the confidentiality and integrity of such data;
(viii) provide partners in the partnership with plan-specific, confidential feedback on any aberrant billing patterns or potential fraud identified by the partnership with respect to such partner;
(ix) establish a process by which entities described in subparagraph (A) may enter the partnership and requirements such entities must meet to enter the partnership;
(x) provide appropriate training, outreach, and education to partners based on the results of data analyses described in clauses (ii) and (iii); and
(xi) perform such other duties as the Secretary determines appropriate.
(D) Substance use disorder treatment analysis
(E) Executive board
(i) Executive board composition(I) In general(II) Chairs
(ii) Meetings
(iii) Executive board duties
The duties of the executive board shall include the following:
(I) Providing strategic direction for the partnership, including membership criteria and a mission statement.(II) Communicating with the leadership of the Department of Health and Human Services and the Department of Justice and the various private health sector associations.
(F) Reports
Not later than January 1, 2023, and every 2 years thereafter, the Secretary shall submit to Congress and make available on the public website of the Centers for Medicare & Medicaid Services a report containing—
(i) a review of activities conducted by the partnership over the 2-year period ending on the date of the submission of such report, including any progress to any objectives established by the partnership;
(ii) any savings voluntarily reported by health plans participating in the partnership attributable to the partnership during such period;
(iii) any savings to the Federal Government attributable to the partnership during such period;
(iv) any other outcomes attributable to the partnership, as determined by the Secretary, during such period; and
(v) a strategic plan for the 2-year period beginning on the day after the date of the submission of such report, including a description of any emerging fraud and abuse schemes, trends, or practices that the partnership intends to study during such period.
(G) Funding
(H) Transitional provisions
(I) Nonapplicability of FACA
(J) Implementation
(K) Definition
For purposes of this paragraph, the term “trusted third party” means an entity that—
(i) demonstrates the capability to carry out the duties of the partnership described in subparagraph (C);
(ii) complies with such conflict of interest standards determined appropriate by the Secretary; and
(iii) meets such other requirements as the Secretary may prescribe.
(b) Additional use of funds by Inspector General
(1) Reimbursements for investigations
(2) Crediting
(c) “Health plan” defined
For purposes of this section, the term “health plan” means a plan or program that provides health benefits, whether directly, through insurance, or otherwise, and includes—
(1) a policy of health insurance;
(2) a contract of a service benefit organization; and
(3) a membership agreement with a health maintenance organization or other prepaid health plan.
(Aug. 14, 1935, ch. 531, title XI, § 1128C, as added Pub. L. 104–191, title II, § 201(a), Aug. 21, 1996, 110 Stat. 1992; amended Pub. L. 111–148, title VI, § 6403(c), Mar. 23, 2010, 124 Stat. 766; Pub. L. 116–260, div. CC, title I, § 124(a), Dec. 27, 2020, 134 Stat. 2957; Pub. L. 117–286, § 4(b)(78), Dec. 27, 2022, 136 Stat. 4351.)

CITE AS: 42 USC 1320a-7c

§ 1320a–7d. Guidance regarding application of health care fraud and abuse sanctions
(a) Solicitation and publication of modifications to existing safe harbors and new safe harbors
(1) In general
(A) Solicitation of proposals for safe harborsNot later than January 1, 1997, and not less than annually thereafter, the Secretary shall publish a notice in the Federal Register soliciting proposals, which will be accepted during a 60-day period, for—
(i) modifications to existing safe harbors issued pursuant to section 14(a) of the Medicare and Medicaid Patient and Program Protection Act of 1987 (42 U.S.C. 1320a–7b note);
(ii) additional safe harbors specifying payment practices that shall not be treated as a criminal offense under section 1320a–7b(b) of this title and shall not serve as the basis for an exclusion under section 1320a–7(b)(7) of this title;
(iii) advisory opinions to be issued pursuant to subsection (b); and
(iv) special fraud alerts to be issued pursuant to subsection (c).
(B) Publication of proposed modifications and proposed additional safe harbors
(C) Report
(2) Criteria for modifying and establishing safe harborsIn modifying and establishing safe harbors under paragraph (1)(B), the Secretary may consider the extent to which providing a safe harbor for the specified payment practice may result in any of the following:
(A) An increase or decrease in access to health care services.
(B) An increase or decrease in the quality of health care services.
(C) An increase or decrease in patient freedom of choice among health care providers.
(D) An increase or decrease in competition among health care providers.
(E) An increase or decrease in the ability of health care facilities to provide services in medically underserved areas or to medically underserved populations.
(F) An increase or decrease in the cost to Federal health care programs (as defined in section 1320a–7b(f) of this title).
(G) An increase or decrease in the potential overutilization of health care services.
(H) The existence or nonexistence of any potential financial benefit to a health care professional or provider which may vary based on their decisions of—
(i) whether to order a health care item or service; or
(ii) whether to arrange for a referral of health care items or services to a particular practitioner or provider.
(I) Any other factors the Secretary deems appropriate in the interest of preventing fraud and abuse in Federal health care programs (as so defined).
(3) Consideration of safe harbor for certain contingency management interventions
(A) In general
(B) Report
(b) Advisory opinions
(1) Issuance of advisory opinions
(2) Matters subject to advisory opinionsThe Secretary shall issue advisory opinions as to the following matters:
(A) What constitutes prohibited remuneration within the meaning of section 1320a–7b(b) of this title or section 1320a–7a(i)(6) of this title.
(B) Whether an arrangement or proposed arrangement satisfies the criteria set forth in section 1320a–7b(b)(3) of this title for activities which do not result in prohibited remuneration.
(C) Whether an arrangement or proposed arrangement satisfies the criteria which the Secretary has established, or shall establish by regulation for activities which do not result in prohibited remuneration.
(D) What constitutes an inducement to reduce or limit services to individuals entitled to benefits under subchapter XVIII or subchapter XIX within the meaning of section 1320a–7a(b) of this title.
(E) Whether any activity or proposed activity constitutes grounds for the imposition of a sanction under section 1320a–7, 1320a–7a, or 1320a–7b of this title.
(3) Matters not subject to advisory opinionsSuch advisory opinions shall not address the following matters:
(A) Whether the fair market value shall be, or was paid or received for any goods, services or property.
(B) Whether an individual is a bona fide employee within the requirements of section 3121(d)(2) of the Internal Revenue Code of 1986.
(4) Effect of advisory opinions
(A) Binding as to Secretary and parties involved
(B) Failure to seek opinion
(5) Regulations
(A) In generalNot later than 180 days after August 21, 1996, the Secretary shall issue regulations to carry out this section. Such regulations shall provide for—
(i) the procedure to be followed by a party applying for an advisory opinion;
(ii) the procedure to be followed by the Secretary in responding to a request for an advisory opinion;
(iii) the interval in which the Secretary shall respond;
(iv) the reasonable fee to be charged to the party requesting an advisory opinion; and
(v) the manner in which advisory opinions will be made available to the public.
(B) Specific contentsUnder the regulations promulgated pursuant to subparagraph (A)—
(i) the Secretary shall be required to issue to a party requesting an advisory opinion by not later than 60 days after the request is received; and
(ii) the fee charged to the party requesting an advisory opinion shall be equal to the costs incurred by the Secretary in responding to the request.
(6) Application of subsection
(c) Special fraud alerts
(1) In general
(A) Request for special fraud alerts
(B)
(2) Criteria for special fraud alertsIn determining whether to issue a special fraud alert upon a request described in paragraph (1), the Inspector General may consider—
(A) whether and to what extent the practices that would be identified in the special fraud alert may result in any of the consequences described in subsection (a)(2); and
(B) the volume and frequency of the conduct that would be identified in the special fraud alert.
(Aug. 14, 1935, ch. 531, title XI, § 1128D, as added Pub. L. 104–191, title II, § 205, Aug. 21, 1996, 110 Stat. 2000; amended Pub. L. 105–33, title IV, § 4331(a)(1), Aug. 5, 1997, 111 Stat. 395; Pub. L. 105–277, div. J, title V, § 5201(c), Oct. 21, 1998, 112 Stat. 2681–917; Pub. L. 106–554, § 1(a)(6) [title V, § 543], Dec. 21, 2000, 114 Stat. 2763, 2763A–551; Pub. L. 117–286, § 4(b)(79), Dec. 27, 2022, 136 Stat. 4351; Pub. L. 117–328, div. FF, title IV, § 4127, Dec. 29, 2022, 136 Stat. 5915.)

CITE AS: 42 USC 1320a-7d

§ 1320a–7e. Health care fraud and abuse data collection program
(a) In general
(b) Reporting of information
(1) In general
(2) Information to be reportedThe information to be reported under paragraph (1) includes:
(A) The name and TIN (as defined in section 7701(a)(41) of the Internal Revenue Code of 1986) of any health care provider, supplier, or practitioner who is the subject of a final adverse action.
(B) The name (if known) of any health care entity with which a health care provider, supplier, or practitioner, who is the subject of a final adverse action, is affiliated or associated.
(C) The nature of the final adverse action and whether such action is on appeal.
(D) A description of the acts or omissions and injuries upon which the final adverse action was based, and such other information as the Secretary determines by regulation is required for appropriate interpretation of information reported under this section.
(3) Confidentiality
(4) Timing and form of reporting
(5) To whom reported
(6) Sanctions for failure to report
(A) Health plans
(B) Governmental agencies
(c) Disclosure and correction of information
(1) DisclosureWith respect to the information about final adverse actions (not including settlements in which no findings of liability have been made) reported to the Secretary under this section with respect to a health care provider, supplier, or practitioner, the Secretary shall, by regulation, provide for—
(A) disclosure of the information, upon request, to the health care provider, supplier, or licensed practitioner, and
(B) procedures in the case of disputed accuracy of the information.
(2) Corrections
(d) Access to reported information
(1) Availability
(2) Fees for disclosure
(e) Protection from liability for reporting
(f) Appropriate coordination
(g) Definitions and special rulesFor purposes of this section:
(1) Final adverse action
(A) In generalThe term “final adverse action” includes:
(i) Civil judgments against a health care provider, supplier, or practitioner in Federal or State court related to the delivery of a health care item or service.
(ii) Federal or State criminal convictions related to the delivery of a health care item or service.
(iii) Actions by Federal agencies responsible for the licensing and certification of health care providers, suppliers, and licensed health care practitioners, including—(I) formal or official actions, such as revocation or suspension of a license (and the length of any such suspension), reprimand, censure or probation,(II) any dismissal or closure of the proceedings by reason of the provider, supplier, or practitioner surrendering their license or leaving the State or jurisdiction 1
1 So in original. Probably should be followed by a comma.
(III) any other loss of license or the right to apply for, or renew, a license of the provider, supplier, or practitioner, whether by operation of law, voluntary surrender, non-renewability, or otherwise, or(IV) any other negative action or finding by such Federal agency that is publicly available information.
(iv) Exclusion from participation in a Federal health care program (as defined in section 1320a–7b(f) of this title).
(v) Any other adjudicated actions or decisions that the Secretary shall establish by regulation.
(B) Exception
(2) Practitioner
(3) Government agencyThe term “Government agency” shall include:
(A) The Department of Justice.
(B) The Department of Health and Human Services.
(C) Any other Federal agency that either administers or provides payment for the delivery of health care services, including, but not limited to the Department of Defense and the Department of Veterans Affairs.
(D) Federal agencies responsible for the licensing and certification of health care providers and licensed health care practitioners.
(4) Health plan
(5) Determination of conviction
(Aug. 14, 1935, ch. 531, title XI, § 1128E, as added Pub. L. 104–191, title II, § 221(a), Aug. 21, 1996, 110 Stat. 2009; amended Pub. L. 105–33, title IV, § 4331(a)(2), (b), (d), Aug. 5, 1997, 111 Stat. 395, 396; Pub. L. 111–148, title VI, § 6403(a), Mar. 23, 2010, 124 Stat. 763.)

CITE AS: 42 USC 1320a-7e

§ 1320a–7f. Coordination of medicare and medicaid surety bond provisions

In the case of a home health agency that is subject to a surety bond requirement under subchapter XVIII and subchapter XIX, the surety bond provided to satisfy the requirement under one such subchapter shall satisfy the requirement under the other such subchapter so long as the bond applies to guarantee return of overpayments under both such subchapters.

(Aug. 14, 1935, ch. 531, title XI, § 1128F, as added Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 304(b)], Nov. 29, 1999, 113 Stat. 1536, 1501A–361.)

CITE AS: 42 USC 1320a-7f

§ 1320a–7g. Funds to reduce medicaid fraud and abuse
(1) In general
For purposes of reducing fraud and abuse in the Medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]—
(A) there is appropriated to the Office of the Inspector General of the Department of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $25,000,000, for fiscal year 2009; and
(B) there is authorized to be appropriated to such Office $25,000,000 for fiscal year 2010 and each subsequent fiscal year.
Amounts appropriated under this section shall remain available for expenditure until expended and shall be in addition to any other amounts appropriated or made available to such Office for such purposes with respect to the Medicaid program.
(2) Annual report
(Pub. L. 110–252, title VII, § 7001(b), June 30, 2008, 122 Stat. 2389.)

CITE AS: 42 USC 1320a-7g

§ 1320a–7h. Transparency reports and reporting of physician ownership or investment interests
(a) Transparency reports
(1) Payments or other transfers of value
(A) In generalOn March 31, 2013, and on the 90th day of each calendar year beginning thereafter, any applicable manufacturer that provides a payment or other transfer of value to a covered recipient (or to an entity or individual at the request of or designated on behalf of a covered recipient), shall submit to the Secretary, in such electronic form as the Secretary shall require, the following information with respect to the preceding calendar year:
(i) The name of the covered recipient.
(ii) The business address of the covered recipient and, in the case of a covered recipient who is a physician, the specialty and National Provider Identifier of the covered recipient.
(iii) The amount of the payment or other transfer of value.
(iv) The dates on which the payment or other transfer of value was provided to the covered recipient.
(v) A description of the form of the payment or other transfer of value, indicated (as appropriate for all that apply) as—(I) cash or a cash equivalent;(II) in-kind items or services;(III) stock, a stock option, or any other ownership interest, dividend, profit, or other return on investment; or(IV) any other form of payment or other transfer of value (as defined by the Secretary).
(vi) A description of the nature of the payment or other transfer of value, indicated (as appropriate for all that apply) as—(I) consulting fees;(II) compensation for services other than consulting;(III) honoraria;(IV) gift;(V) entertainment;(VI) food;(VII) travel (including the specified destinations);(VIII) education;(IX) research;(X) charitable contribution;(XI) royalty or license;(XII) current or prospective ownership or investment interest;(XIII) direct compensation for serving as faculty or as a speaker for a medical education program;(XIV) grant; or(XV) any other nature of the payment or other transfer of value (as defined by the Secretary).
(vii) If the payment or other transfer of value is related to marketing, education, or research specific to a covered drug, device, biological, or medical supply, the name of that covered drug, device, biological, or medical supply.
(viii) Any other categories of information regarding the payment or other transfer of value the Secretary determines appropriate.
(B) Special rule for certain payments or other transfers of value
(2) Physician ownershipIn addition to the requirement under paragraph (1)(A), on March 31, 2013, and on the 90th day of each calendar year beginning thereafter, any applicable manufacturer or applicable group purchasing organization shall submit to the Secretary, in such electronic form as the Secretary shall require, the following information regarding any ownership or investment interest (other than an ownership or investment interest in a publicly traded security and mutual fund, as described in section 1395nn(c) of this title) held by a physician (or an immediate family member of such physician (as defined for purposes of section 1395nn(a) of this title)) in the applicable manufacturer or applicable group purchasing organization during the preceding year:
(A) The dollar amount invested by each physician holding such an ownership or investment interest.
(B) The value and terms of each such ownership or investment interest.
(C) Any payment or other transfer of value provided to a physician holding such an ownership or investment interest (or to an entity or individual at the request of or designated on behalf of a physician holding such an ownership or investment interest), including the information described in clauses (i) through (viii) of paragraph (1)(A), except that in applying such clauses, “physician” shall be substituted for “covered recipient” each place it appears.
(D) Any other information regarding the ownership or investment interest the Secretary determines appropriate.
(b) Penalties for noncompliance
(1) Failure to report
(A) In general
(B) Limitation
(2) Knowing failure to report
(A) In general
(B) Limitation
(3) Use of funds
(c) Procedures for submission of information and public availability
(1) In general
(A) EstablishmentNot later than October 1, 2011, the Secretary shall establish procedures—
(i) for applicable manufacturers and applicable group purchasing organizations to submit information to the Secretary under subsection (a); and
(ii) for the Secretary to make such information submitted available to the public.
(B) Definition of terms
(C) Public availabilityExcept as provided in subparagraph (E), the procedures established under subparagraph (A)(ii) shall ensure that, not later than September 30, 2013, and on June 30 of each calendar year beginning thereafter, the information submitted under subsection (a) with respect to the preceding calendar year is made available through an Internet website that—
(i) is searchable and is in a format that is clear and understandable;
(ii) contains information that is presented by the name of the applicable manufacturer or applicable group purchasing organization, the name of the covered recipient, the business address of the covered recipient, the specialty of the covered recipient, the value of the payment or other transfer of value, the date on which the payment or other transfer of value was provided to the covered recipient, the form of the payment or other transfer of value, indicated (as appropriate) under subsection (a)(1)(A)(v), the nature of the payment or other transfer of value, indicated (as appropriate) under subsection (a)(1)(A)(vi), and the name of the covered drug, device, biological, or medical supply, as applicable;
(iii) contains information that is able to be easily aggregated and downloaded;
(iv) contains a description of any enforcement actions taken to carry out this section, including any penalties imposed under subsection (b), during the preceding year;
(v) contains background information on industry-physician relationships;
(vi) in the case of information submitted with respect to a payment or other transfer of value described in subparagraph (E)(i), lists such information separately from the other information submitted under subsection (a) and designates such separately listed information as funding for clinical research;
(vii) contains any other information the Secretary determines would be helpful to the average consumer;
(viii) in the case of information made available under this subparagraph prior to January 1, 2022, does not contain the National Provider Identifier of the covered recipient, and
(ix) subject to subparagraph (D), provides the applicable manufacturer, applicable group purchasing organization, or covered recipient an opportunity to review and submit corrections to the information submitted with respect to the applicable manufacturer, applicable group purchasing organization, or covered recipient, respectively, for a period of not less than 45 days prior to such information being made available to the public.
(D) Clarification of time period for review and corrections
(E) Delayed publication for payments made pursuant to product research or development agreements and clinical investigations
(i) In generalIn the case of information submitted under subsection (a) with respect to a payment or other transfer of value made to a covered recipient by an applicable manufacturer pursuant to a product research or development agreement for services furnished in connection with research on a potential new medical technology or a new application of an existing medical technology or the development of a new drug, device, biological, or medical supply, or by an applicable manufacturer in connection with a clinical investigation regarding a new drug, device, biological, or medical supply, the procedures established under subparagraph (A)(ii) shall provide that such information is made available to the public on the first date described in the matter preceding clause (i) in subparagraph (C) after the earlier of the following:(I) The date of the approval or clearance of the covered drug, device, biological, or medical supply by the Food and Drug Administration.(II) Four calendar years after the date such payment or other transfer of value was made.
(ii) Confidentiality of information prior to publication
(2) Consultation
(d) Annual reports and relation to State laws
(1) Annual report to CongressNot later than April 1 of each year beginning with 2013, the Secretary shall submit to Congress a report that includes the following:
(A) The information submitted under subsection (a) during the preceding year, aggregated for each applicable manufacturer and applicable group purchasing organization that submitted such information during such year (except, in the case of information submitted with respect to a payment or other transfer of value described in subsection (c)(1)(E)(i), such information shall be included in the first report submitted to Congress after the date on which such information is made available to the public under such subsection).
(B) A description of any enforcement actions taken to carry out this section, including any penalties imposed under subsection (b), during the preceding year.
(2) Annual reports to States
(3) Relation to State laws
(A)In general.—In the case of a payment or other transfer of value provided by an applicable manufacturer that is received by a covered recipient (as defined in subsection (e)) on or after January 1, 2012, subject to subparagraph (B), the provisions of this section shall preempt any statute or regulation of a State or of a political subdivision of a State that requires an applicable manufacturer (as so defined) to disclose or report, in any format, the type of information (as described in subsection (a)) regarding such payment or other transfer of value.
(B)No preemption of additional requirements.—Subparagraph (A) shall not preempt any statute or regulation of a State or of a political subdivision of a State that requires the disclosure or reporting of information—
(i) not of the type required to be disclosed or reported under this section;
(ii) described in subsection (e)(10)(B), except in the case of information described in clause (i) of such subsection;
(iii) by any person or entity other than an applicable manufacturer (as so defined) or a covered recipient (as defined in subsection (e)); or
(iv) to a Federal, State, or local governmental agency for public health surveillance, investigation, or other public health purposes or health oversight purposes.
(C) Nothing in subparagraph (A) shall be construed to limit the discovery or admissibility of information described in such subparagraph in a criminal, civil, or administrative proceeding.
(4) Consultation
(e) DefinitionsIn this section:
(1) Applicable group purchasing organization
(2) Applicable manufacturer
(3) Clinical investigation
(4) Covered device
(5) Covered drug, device, biological, or medical supply
(6) Covered recipient
(A) In generalExcept as provided in subparagraph (B), the term “covered recipient” means the following:
(i) A physician.
(ii) A teaching hospital.
(iii) A physician assistant, nurse practitioner, or clinical nurse specialist (as such terms are defined in section 1395x(aa)(5) of this title).
(iv) A certified registered nurse anesthetist (as defined in section 1395x(bb)(2) of this title).
(v) A certified nurse-midwife (as defined in section 1395x(gg)(2) of this title).
(B) Exclusion
(7) Employee
(8) Knowingly
(9) Manufacturer of a covered drug, device, biological, or medical supply
(10) Payment or other transfer of value
(A) In general
(B) ExclusionsAn applicable manufacturer shall not be required to submit information under subsection (a) with respect to the following:
(i) A transfer of anything the value of which is less than $10, unless the aggregate amount transferred to, requested by, or designated on behalf of the covered recipient by the applicable manufacturer during the calendar year exceeds $100. For calendar years after 2012, the dollar amounts specified in the preceding sentence shall be increased by the same percentage as the percentage increase in the consumer price index for all urban consumers (all items; U.S. city average) for the 12-month period ending with June of the previous year.
(ii) Product samples that are not intended to be sold and are intended for patient use.
(iii) Educational materials that directly benefit patients or are intended for patient use.
(iv) The loan of a covered device for a short-term trial period, not to exceed 90 days, to permit evaluation of the covered device by the covered recipient.
(v) Items or services provided under a contractual warranty, including the replacement of a covered device, where the terms of the warranty are set forth in the purchase or lease agreement for the covered device.
(vi) A transfer of anything of value to a covered recipient when the covered recipient is a patient and not acting in the professional capacity of a covered recipient.
(vii) Discounts (including rebates).
(viii) In-kind items used for the provision of charity care.
(ix) A dividend or other profit distribution from, or ownership or investment interest in, a publicly traded security and mutual fund (as described in section 1395nn(c) of this title).
(x) In the case of an applicable manufacturer who offers a self-insured plan, payments for the provision of health care to employees under the plan.
(xi) In the case of a covered recipient who is a licensed non-medical professional, a transfer of anything of value to the covered recipient if the transfer is payment solely for the non-medical professional services of such licensed non-medical professional.
(xii) In the case of a covered recipient who is a physician, a transfer of anything of value to the covered recipient if the transfer is payment solely for the services of the covered recipient with respect to a civil or criminal action or an administrative proceeding.
(11) Physician
(Aug. 14, 1935, ch. 531, title XI, § 1128G, as added Pub. L. 111–148, title VI, § 6002, Mar. 23, 2010, 124 Stat. 689; amended Pub. L. 115–271, title VI, § 6111(a)(1), (b), Oct. 24, 2018, 132 Stat. 4006, 4007.)

CITE AS: 42 USC 1320a-7h

§ 1320a–7i. Reporting of information relating to drug samples
(a) In general
(1) In the case of a manufacturer or authorized distributor of record which makes distributions by mail or common carrier under subsection (d)(2) of section 353 of title 21, the identity and quantity of drug samples requested and the identity and quantity of drug samples distributed under such subsection during that year, aggregated by—
(A) the name, address, professional designation, and signature of the practitioner making the request under subparagraph (A)(i) of such subsection, or of any individual who makes or signs for the request on behalf of the practitioner; and
(B) any other category of information determined appropriate by the Secretary.
(2) In the case of a manufacturer or authorized distributor of record which makes distributions by means other than mail or common carrier under subsection (d)(3) of such section 353 of title 21, the identity and quantity of drug samples requested and the identity and quantity of drug samples distributed under such subsection during that year, aggregated by—
(A) the name, address, professional designation, and signature of the practitioner making the request under subparagraph (A)(i) of such subsection, or of any individual who makes or signs for the request on behalf of the practitioner; and
(B) any other category of information determined appropriate by the Secretary.
(b) DefinitionsIn this section:
(1) Applicable drugThe term “applicable drug” means a drug—
(A) which is subject to subsection (b) of such section 353 of title 21; and
(B) for which payment is available under subchapter XVIII or a State plan under subchapter XIX or XXI (or a waiver of such a plan).
(2) Authorized distributor of record
(3) Manufacturer
(Aug. 14, 1935, ch. 531, title XI, § 1128H, as added Pub. L. 111–148, title VI, § 6004, Mar. 23, 2010, 124 Stat. 697.)

CITE AS: 42 USC 1320a-7i

§ 1320a–7j. Accountability requirements for facilities
(a) Definition of facilityIn this section, the term “facility” means—
(1) a skilled nursing facility (as defined in section 1395i–3(a) of this title); or
(2) a nursing facility (as defined in section 1396r(a) of this title).
(b) Effective compliance and ethics programs
(1) Requirement
(2) Development of regulations
(A) In general
(B) Design of regulations
(C) Evaluation
(3) Requirements for compliance and ethics programsIn this subsection, the term “compliance and ethics program” means, with respect to a facility, a program of the operating organization that—
(A) has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal, civil, and administrative violations under this chapter and in promoting quality of care; and
(B) includes at least the required components specified in paragraph (4).
(4) Required components of programThe required components of a compliance and ethics program of an operating organization are the following:
(A) The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under this chapter.
(B) Specific individuals within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and have sufficient resources and authority to assure such compliance.
(C) The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under this chapter.
(D) The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, such as by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.
(E) The organization must have taken reasonable steps to achieve compliance with its standards, such as by utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this chapter by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report violations by others within the organization without fear of retribution.
(F) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense.
(G) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including any necessary modification to its program to prevent and detect criminal, civil, and administrative violations under this chapter.
(H) The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities.
(c) Quality assurance and performance improvement program
(1) In general
(2) Regulations
(f)2
2 So in original. No subsecs. (d) and (e) have been enacted.
Standardized complaint form
(1) Development by the Secretary
(2) Complaint forms and resolution processes
(A) Complaint formsThe State must make the standardized complaint form developed under paragraph (1) available upon request to—
(i) a resident of a facility; and
(ii) any person acting on the resident’s behalf.
(B) Complaint resolution processThe State must establish a complaint resolution process in order to ensure that the legal representative of a resident of a facility or other responsible party is not denied access to such resident or otherwise retaliated against if they have complained about the quality of care provided by the facility or other issues relating to the facility. Such complaint resolution process shall include—
(i) procedures to assure accurate tracking of complaints received, including notification to the complainant that a complaint has been received;
(ii) procedures to determine the likely severity of a complaint and for the investigation of the complaint; and
(iii) deadlines for responding to a complaint and for notifying the complainant of the outcome of the investigation.
(3) Rule of construction
(g) Submission of staffing information based on payroll data in a uniform formatBeginning not later than 2 years after March 23, 2010, and after consulting with State long-term care ombudsman programs, consumer advocacy groups, provider stakeholder groups, employees and their representatives, and other parties the Secretary deems appropriate, the Secretary shall require a facility to electronically submit to the Secretary direct care staffing information (including information with respect to agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format (according to specifications established by the Secretary in consultation with such programs, groups, and parties). Such specifications shall require that the information submitted under the preceding sentence—
(1) specify the category of work a certified employee performs (such as whether the employee is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other medical personnel);
(2) include resident census data and information on resident case mix;
(3) include a regular reporting schedule; and
(4) include information on employee turnover and tenure and on the hours of care provided by each category of certified employees referenced in paragraph (1) per resident per day.
Nothing in this subsection shall be construed as preventing the Secretary from requiring submission of such information with respect to specific categories, such as nursing staff, before other categories of certified employees. Information under this subsection with respect to agency and contract staff shall be kept separate from information on employee staffing.
(h) Notification of facility closure
(1) In generalAny individual who is the administrator of a facility must—
(A) submit to the Secretary, the State long-term care ombudsman, residents of the facility, and the legal representatives of such residents or other responsible parties, written notification of an impending closure—
(i) subject to clause (ii), not later than the date that is 60 days prior to the date of such closure; and
(ii) in the case of a facility where the Secretary terminates the facility’s participation under this subchapter, not later than the date that the Secretary determines appropriate;
(B) ensure that the facility does not admit any new residents on or after the date on which such written notification is submitted; and
(C) include in the notice a plan for the transfer and adequate relocation of the residents of the facility by a specified date prior to closure that has been approved by the State, including assurances that the residents will be transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs, choice, and best interests of each resident.
(2) Relocation
(A) In general
(B) Continuation of payments until residents relocated
(3) SanctionsAny individual who is the administrator of a facility that fails to comply with the requirements of paragraph (1)—
(A) shall be subject to a civil monetary penalty of up to $100,000;
(B) may be subject to exclusion from participation in any Federal health care program (as defined in section 1320a–7b(f) of this title); and
(C) shall be subject to any other penalties that may be prescribed by law.
(4) Procedure
(Aug. 14, 1935, ch. 531, title XI, § 1128I, as added and amended Pub. L. 111–148, title VI, §§ 6102, 6105(a), 6106, 6113(a), Mar. 23, 2010, 124 Stat. 702, 711, 712, 718.)

CITE AS: 42 USC 1320a-7j

§ 1320a–7k. Medicare and Medicaid program integrity provisions
(a) Data matching
(1) Integrated data repository
(A) Inclusion of certain data
(i) In general
The Integrated Data Repository of the Centers for Medicare & Medicaid Services shall include, at a minimum, claims and payment data from the following:
(I) The programs under subchapters XVIII and XIX (including parts A, B, C, and D of subchapter XVIII).(II) The program under subchapter XXI.(III) Health-related programs administered by the Secretary of Veterans Affairs.(IV) Health-related programs administered by the Secretary of Defense.(V) The program of old-age, survivors, and disability insurance benefits established under subchapter II.(VI) The Indian Health Service and the Contract Health Service program.
(ii) Priority for inclusion of certain data
(B) Data sharing and matching
(i) In general
(ii) Individuals described
The following individuals are described in this clause:
(I) The Commissioner of Social Security.(II) The Secretary of Veterans Affairs.(III) The Secretary of Defense.(IV) The Director of the Indian Health Service.
(iii) Definition of system of records
(2) Access to claims and payment databases
(b) OIG authority to obtain information
(1) In general
Notwithstanding and in addition to any other provision of law, the Inspector General of the Department of Health and Human Services may, for purposes of protecting the integrity of the programs under subchapters XVIII and XIX, obtain information from any individual (including a beneficiary provided all applicable privacy protections are followed) or entity that—
(A) is a provider of medical or other items or services, supplier, grant recipient, contractor, or subcontractor; or
(B) directly or indirectly provides, orders, manufactures, distributes, arranges for, prescribes, supplies, or receives medical or other items or services payable by any Federal health care program (as defined in section 1320a–7b(f) of this title) regardless of how the item or service is paid for, or to whom such payment is made.
(2) Inclusion of certain information
(c) Administrative remedy for knowing participation by beneficiary in health care fraud scheme
(1) In general
(2) Applicable individual
For purposes of paragraph (1), the term “applicable individual” means an individual—
(A) entitled to, or enrolled for, benefits under part A of subchapter XVIII or enrolled under part B of such subchapter;
(B) eligible for medical assistance under a State plan under subchapter XIX or under a waiver of such plan; or
(C) eligible for child health assistance under a child health plan under subchapter XXI.
(d) Reporting and returning of overpayments
(1) In general
If a person has received an overpayment, the person shall—
(A) report and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address; and
(B) notify the Secretary, State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment.
(2) Deadline for reporting and returning overpayments
An overpayment must be reported and returned under paragraph (1) by the later of—
(A) the date which is 60 days after the date on which the overpayment was identified; or
(B) the date any corresponding cost report is due, if applicable.
(3) Enforcement
(4) Definitions
In this subsection:
(A) Knowing and knowingly
(B) Overpayment
(C) Person
(i) In general
(ii) Exclusion
(e) Inclusion of national provider identifier on all applications and claims
(Aug. 14, 1935, ch. 531, title XI, § 1128J, as added Pub. L. 111–148, title VI, § 6402(a), Mar. 23, 2010, 124 Stat. 753.)

CITE AS: 42 USC 1320a-7k

§ 1320a–7l.
(a)
In general
The Secretary of Health and Human Services (in this section referred to as the “Secretary”), shall establish a program to identify efficient, effective, and economical procedures for long term care facilities or providers to conduct background checks on prospective direct patient access employees on a nationwide basis (in this subsection, such program shall be referred to as the “nationwide program”). Except for the following modifications, the Secretary shall carry out the nationwide program under similar terms and conditions as the pilot program under section 307 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2257), including the prohibition on hiring abusive workers and the authorization of the imposition of penalties by a participating State under subsection (b)(3)(A) and (b)(6), respectively, of such section 307:
(1)
Agreements
(A)
Newly participating States
The Secretary shall enter into agreements with each State—
(i) that the Secretary has not entered into an agreement with under subsection (c)(1) of such section 307;
(ii) that agrees to conduct background checks under the nationwide program on a Statewide basis; and
(iii) that submits an application to the Secretary containing such information and at such time as the Secretary may specify.
(B)
Certain previously participating States
The Secretary shall enter into agreements with each State—
(i) that the Secretary has entered into an agreement with under such subsection (c)(1), but only in the case where such agreement did not require the State to conduct background checks under the program established under subsection (a) of such section 307 on a Statewide basis;
(ii) that agrees to conduct background checks under the nationwide program on a Statewide basis; and
(iii) that submits an application to the Secretary containing such information and at such time as the Secretary may specify.
(2)
Nonapplication of selection criteria
(3)
Required fingerprint check as part of criminal history background check
The procedures established under subsection (b)(1) of such section 307 shall—
(A) require that the long-term care facility or provider (or the designated agent of the long-term care facility or provider) obtain State and national criminal history background checks on the prospective employee through such means as the Secretary determines appropriate, efficient, and effective that utilize a search of State-based abuse and neglect registries and databases, including the abuse and neglect registries of another State in the case where a prospective employee previously resided in that State, State criminal history records, the records of any proceedings in the State that may contain disqualifying information about prospective employees (such as proceedings conducted by State professional licensing and disciplinary boards and State Medicaid Fraud Control Units), and Federal criminal history records, including a fingerprint check using the Integrated Automated Fingerprint Identification System of the Federal Bureau of Investigation;
(B) require States to describe and test methods that reduce duplicative fingerprinting, including providing for the development of “rap back” capability by the State such that, if a direct patient access employee of a long-term care facility or provider is convicted of a crime following the initial criminal history background check conducted with respect to such employee, and the employee’s fingerprints match the prints on file with the State law enforcement department, the department will immediately inform the State and the State will immediately inform the long-term care facility or provider which employs the direct patient access employee of such conviction; and
(C) require that criminal history background checks conducted under the nationwide program remain valid for a period of time specified by the Secretary.
(4)
State requirements
An agreement entered into under paragraph (1) shall require that a participating State—
(A) be responsible for monitoring compliance with the requirements of the nationwide program;
(B) have procedures in place to—
(i) conduct screening and criminal history background checks under the nationwide program in accordance with the requirements of this section;
(ii) monitor compliance by long-term care facilities and providers with the procedures and requirements of the nationwide program;
(iii) as appropriate, provide for a provisional period of employment by a long-term care facility or provider of a direct patient access employee, not to exceed 60 days, pending completion of the required criminal history background check and, in the case where the employee has appealed the results of such background check, pending completion of the appeals process, during which the employee shall be subject to direct on-site supervision (in accordance with procedures established by the State to ensure that a long-term care facility or provider furnishes such direct on-site supervision);
(iv) provide an independent process by which a provisional employee or an employee may appeal or dispute the accuracy of the information obtained in a background check performed under the nationwide program, including the specification of criteria for appeals for direct patient access employees found to have disqualifying information which shall include consideration of the passage of time, extenuating circumstances, demonstration of rehabilitation, and relevancy of the particular disqualifying information with respect to the current employment of the individual;
(v) provide for the designation of a single State agency as responsible for—(I) overseeing the coordination of any State and national criminal history background checks requested by a long-term care facility or provider (or the designated agent of the long-term care facility or provider) utilizing a search of State and Federal criminal history records, including a fingerprint check of such records;(II) overseeing the design of appropriate privacy and security safeguards for use in the review of the results of any State or national criminal history background checks conducted regarding a prospective direct patient access employee to determine whether the employee has any conviction for a relevant crime;(III) immediately reporting to the long-term care facility or provider that requested the criminal history background check the results of such review; and(IV) in the case of an employee with a conviction for a relevant crime that is subject to reporting under section 1128E of the Social Security Act (42 U.S.C. 1320a–7e), reporting the existence of such conviction to the database established under that section;
(vi) determine which individuals are direct patient access employees (as defined in paragraph (6)(B)) for purposes of the nationwide program;
(vii) as appropriate, specify offenses, including convictions for violent crimes, for purposes of the nationwide program; and
(viii) describe and test methods that reduce duplicative fingerprinting, including providing for the development of “rap back” capability such that, if a direct patient access employee of a long-term care facility or provider is convicted of a crime following the initial criminal history background check conducted with respect to such employee, and the employee’s fingerprints match the prints on file with the State law enforcement department—(I) the department will immediately inform the State agency designated under clause (v) and such agency will immediately inform the facility or provider which employs the direct patient access employee of such conviction; and(II) the State will provide, or will require the facility to provide, to the employee a copy of the results of the criminal history background check conducted with respect to the employee at no charge in the case where the individual requests such a copy.
(5)
Payments
(A)
Newly participating States
(i)
In general
(ii)
Federal match
(B)
Previously participating States
(i)
In general
(ii)
Federal match
(6)
Definitions
Under the nationwide program:
(A)
Conviction for a relevant crime
The term “conviction for a relevant crime” means any Federal or State criminal conviction for—
(i) any offense described in section 1128(a) of the Social Security Act (42 U.S.C. 1320a–7[(a)]); or
(ii) such other types of offenses as a participating State may specify for purposes of conducting the program in such State.
(B)
Disqualifying information
(C)
Finding of patient or resident abuse
The term “finding of patient or resident abuse” means any substantiated finding by a State agency under section 1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security Act (42 U.S.C. 1395i–3(g)(1)(C), 1396r(g)(1)(C)) or a Federal agency that a direct patient access employee has committed—
(i) an act of patient or resident abuse or neglect or a misappropriation of patient or resident property; or
(ii) such other types of acts as a participating State may specify for purposes of conducting the program in such State.
(D)
Direct patient access employee
(E)
Long-term care facility or provider
The term “long-term care facility or provider” means the following facilities or providers which receive payment for services under title XVIII or XIX of the Social Security Act [42 U.S.C. 1395 et seq., 1396 et seq.]:
(i) A skilled nursing facility (as defined in section 1819(a) of the Social Security Act (42 U.S.C. 1395i–3(a))).
(ii) A nursing facility (as defined in section 1919(a) of such Act (42 U.S.C. 1396r(a))).
(iii) A home health agency.
(iv) A provider of hospice care (as defined in section 1861(dd)(1) of such Act (42 U.S.C. 1395x(dd)(1))).
(v) A long-term care hospital (as described in section 1886(d)(1)(B)(iv) of such Act (42 U.S.C. 1395ww(d)(1)(B)(iv))).
(vi) A provider of personal care services.
(vii) A provider of adult day care.
(viii) A residential care provider that arranges for, or directly provides, long-term care services, including an assisted living facility that provides a level of care established by the Secretary.
(ix) An intermediate care facility for the mentally retarded (as defined in section 1905(d) of such Act (42 U.S.C. 1396d(d))).
(x) Any other facility or provider of long-term care services under such titles as the participating State determines appropriate.
(7)
Evaluation and report
(A)
Evaluation
(i)
In general
(ii)
Inclusion of specific topics
The evaluation conducted under clause (i) shall include the following:(I) A review of the various procedures implemented by participating States for long-term care facilities or providers, including staffing agencies, to conduct background checks of direct patient access employees under the nationwide program and identification of the most appropriate, efficient, and effective procedures for conducting such background checks.(II) An assessment of the costs of conducting such background checks (including start up and administrative costs).(III) A determination of the extent to which conducting such background checks leads to any unintended consequences, including a reduction in the available workforce for long-term care facilities or providers.(IV) An assessment of the impact of the nationwide program on reducing the number of incidents of neglect, abuse, and misappropriation of resident property to the extent practicable.(V) An evaluation of other aspects of the nationwide program, as determined appropriate by the Secretary.
(B)
Report
(b)
Funding
(1)
Notification
(2)
Transfer of funds
(A)
In general
(B)
Reservation of funds for conduct of evaluation
(Pub. L. 111–148, title VI, § 6201, Mar. 23, 2010, 124 Stat. 721.)

CITE AS: 42 USC 1320a-7l

§ 1320a–7m. Use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the Medicare fee-for-service program
(a) Use in the Medicare fee-for-service program
(b) Predictive analytics technologies requirementsThe predictive analytics technologies used by the Secretary shall—
(1) capture Medicare provider and Medicare beneficiary activities across the Medicare fee-for-service program to provide a comprehensive view across all providers, beneficiaries, and geographies within such program in order to—
(A) identify and analyze Medicare provider networks, provider billing patterns, and beneficiary utilization patterns; and
(B) identify and detect any such patterns and networks that represent a high risk of fraudulent activity;
(2) be integrated into the existing Medicare fee-for-service program claims flow with minimal effort and maximum efficiency;
(3) be able to—
(A) analyze large data sets for unusual or suspicious patterns or anomalies or contain other factors that are linked to the occurrence of waste, fraud, or abuse;
(B) undertake such analysis before payment is made; and
(C) prioritize such identified transactions for additional review before payment is made in terms of the likelihood of potential waste, fraud, and abuse to more efficiently utilize investigative resources;
(4) capture outcome information on adjudicated claims for reimbursement to allow for refinement and enhancement of the predictive analytics technologies on the basis of such outcome information, including post-payment information about the eventual status of a claim; and
(5) prevent the payment of claims for reimbursement that have been identified as potentially wasteful, fraudulent, or abusive until such time as the claims have been verified as valid.
(c) Implementation requirements
(1) Request for proposalsNot later than January 1, 2011, the Secretary shall issue a request for proposals to carry out this section during the first year of implementation. To the extent the Secretary determines appropriate—
(A) the initial request for proposals may include subsequent implementation years; and
(B) the Secretary may issue additional requests for proposals with respect to subsequent implementation years.
(2) First implementation year
(3) Second implementation year
(4) Third implementation year
(5) Fourth implementation year
(6) Option for refinement and evaluation
(d) Contractor selection, qualifications, and data access requirements
(1) Selection
(A) In general
(B) Number of contractors
(2) Qualifications
(A) In generalThe Secretary shall enter into a contract under this section with an entity only if the entity—
(i) has leadership and staff who—(I) have the appropriate clinical knowledge of, and experience with, the payment rules and regulations under the Medicare fee-for-service program; and(II) have direct management experience and proficiency utilizing predictive analytics technologies necessary to carry out the requirements under subsection (b); or
(ii) has a contract, or will enter into a contract, with another entity that has leadership and staff meeting the criteria described in clause (i).
(B) Conflict of interest
(3) Data access
(e) Reporting requirements
(1) First implementation year reportNot later than 3 months after the completion of the first implementation year under this section, the Secretary shall submit to the appropriate committees of Congress and make available to the public a report that includes the following:
(A) A description of the implementation of the use of predictive analytics technologies during the year.
(B) A certification of the Inspector General of the Department of Health and Human Services that—
(i) specifies the actual and projected savings to the Medicare fee-for-service program as a result of the use of predictive analytics technologies, including estimates of the amounts of such savings with respect to both improper payments recovered and improper payments avoided;
(ii) the actual and projected savings to the Medicare fee-for-service program as a result of such use of predictive analytics technologies relative to the return on investment for the use of such technologies and in comparison to other strategies or technologies used to prevent and detect fraud, waste, and abuse in the Medicare fee-for-service program; and
(iii) includes recommendations regarding—(I) whether the Secretary should continue to use predictive analytics technologies;(II) whether the use of such technologies should be expanded in accordance with the requirements of subsection (c); and(III) any modifications or refinements that should be made to increase the amount of actual or projected savings or mitigate any adverse impact on Medicare beneficiaries or providers.
(C) An analysis of the extent to which the use of predictive analytics technologies successfully prevented and detected waste, fraud, or abuse in the Medicare fee-for-service program.
(D) A review of whether the predictive analytics technologies affected access to, or the quality of, items and services furnished to Medicare beneficiaries.
(E) A review of what effect, if any, the use of predictive analytics technologies had on Medicare providers.
(F) Any other items determined appropriate by the Secretary.
(2) Second year implementation report
(3) Third year implementation reportNot later than 3 months after the completion of the third implementation year under this section, the Secretary shall submit to the appropriate committees of Congress, and make available to the public, a report that includes 1
1 So in original. Probably should be followed by a comma.
with respect to such year, the items required under paragraph (1),2
2 So in original. The comma probably should not appear.
as well as any other additional items determined appropriate by the Secretary with respect to the report for such year, and the following:
(A) An analysis of the cost-effectiveness and feasibility of expanding the use of predictive analytics technologies to Medicaid and CHIP.
(B) An analysis of the effect, if any, the application of predictive analytics technologies to claims under Medicaid and CHIP would have on States and the commonwealths and territories.
(C) Recommendations regarding the extent to which technical assistance may be necessary to expand the application of predictive analytics technologies to claims under Medicaid and CHIP, and the type of any such assistance.
(f) Independent evaluation and report
(1) Evaluation
(2) Report
(g) Waiver authority
(h) Funding
(1) Appropriation
(2) Reservations
(A) Independent evaluation
(B) Application to Medicaid and CHIP
(i) DefinitionsIn this section:
(1) Commonwealths and territories
(2) CHIP
(3) Medicaid
(4) Medicare beneficiary
(5) Medicare fee-for-service program
(6) Medicare provider
(7) Secretary
(8) State
(Pub. L. 111–240, title IV, § 4241, Sept. 27, 2010, 124 Stat. 2599.)

CITE AS: 42 USC 1320a-7m

§ 1320a–7n. Disclosure of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse
(a) Reference to predictive modeling technologies requirements
(b) Limiting disclosure of predictive modeling technologies
In implementing such provisions under such section 1320a–7m with respect to covered algorithms (as defined in subsection (c)), the following shall apply:
(1) Nonapplication of FOIA
(2) Limitation with respect to use and disclosure of information by State agencies
(A) In general
(B) Information security
(C) Procedural requirements
(c) Covered algorithm defined
In this section, the term “covered algorithm”—
(1) means a predictive modeling or other analytics technology, as used for purposes of section 1320a–7m(a) of this title to identify and prevent waste, fraud, and abuse with respect to the Medicare program under subchapter XVIII, the Medicaid program under subchapter XIX, and the Children’s Health Insurance Program under subchapter XXI; and
(2) includes the mathematical expressions utilized in the application of such technology and the means by which such technology is developed.
(

CITE AS: 42 USC 1320a-7n

§ 1320a–8. Civil monetary penalties and assessments for subchapters II, VIII and XVI
(a) False statements or representations of material fact; proceedings to exclude; wrongful conversions by representative payees
(1) Any person (including an organization, agency, or other entity) who—
(A) makes, or causes to be made, a statement or representation of a material fact, for use in determining any initial or continuing right to or the amount of monthly insurance benefits under subchapter II or benefits or payments under subchapter VIII or XVI, that the person knows or should know is false or misleading,
(B) makes such a statement or representation for such use with knowing disregard for the truth, or
(C) omits from a statement or representation for such use, or otherwise withholds disclosure of, a fact which the person knows or should know is material to the determination of any initial or continuing right to or the amount of monthly insurance benefits under subchapter II or benefits or payments under subchapter VIII or XVI, if the person knows, or should know, that the statement or representation with such omission is false or misleading or that the withholding of such disclosure is misleading,
shall be subject to, in addition to any other penalties that may be prescribed by law, a civil money penalty of not more than $5,000 for each such statement or representation or each receipt of such benefits or payments while withholding disclosure of such fact, except that in the case of such a person who receives a fee or other income for services performed in connection with any such determination (including a claimant representative, translator, or current or former employee of the Social Security Administration) or who is a physician or other health care provider who submits, or causes the submission of, medical or other evidence in connection with any such determination, the amount of such penalty shall be not more than $7,500. Such person also shall be subject to an assessment, in lieu of damages sustained by the United States because of such statement or representation or because of such withholding of disclosure of a material fact, of not more than twice the amount of benefits or payments paid as a result of such a statement or representation or such a withholding of disclosure. In addition, the Commissioner of Social Security may make a determination in the same proceeding to recommend that the Secretary exclude, as provided in section 1320a–7 of this title, such a person who is a medical provider or physician from participation in the programs under subchapter XVIII.
(2) For purposes of this section, a material fact is one which the Commissioner of Social Security may consider in evaluating whether an applicant is entitled to benefits under subchapter II or subchapter VIII, or eligible for benefits or payments under subchapter XVI.
(3) Any person (including an organization, agency, or other entity) who, having received, while acting in the capacity of a representative payee pursuant to section 405(j), 1007, or 1383(a)(2) of this title, a payment under subchapter II, VIII, or XVI for the use and benefit of another individual, converts such payment, or any part thereof, to a use that such person knows or should know is other than for the use and benefit of such other individual shall be subject to, in addition to any other penalties that may be prescribed by law, a civil money penalty of not more than $5,000 for each such conversion. Such person shall also be subject to an assessment, in lieu of damages sustained by the United States resulting from the conversion, of not more than twice the amount of any payments so converted.
(b) Initiation of proceedings; hearing; sanctions
(1) The Commissioner of Social Security may initiate a proceeding to determine whether to impose a civil money penalty or assessment, or whether to recommend exclusion under subsection (a) only as authorized by the Attorney General pursuant to procedures agreed upon by the Commissioner of Social Security and the Attorney General. The Commissioner of Social Security may not initiate an action under this section with respect to any violation described in subsection (a) later than 6 years after the date the violation was committed. The Commissioner of Social Security may initiate an action under this section by serving notice of the action in any manner authorized by Rule 4 of the Federal Rules of Civil Procedure.
(2) The Commissioner of Social Security shall not make a determination adverse to any person under this section until the person has been given written notice and an opportunity for the determination to be made on the record after a hearing at which the person is entitled to be represented by counsel, to present witnesses, and to cross-examine witnesses against the person.
(3) In a proceeding under this section which—
(A) is against a person who has been convicted (whether upon a verdict after trial or upon a plea of guilty or nolo contendere) of a Federal or State crime; and
(B) involves the same transaction as in the criminal action;
the person is estopped from denying the essential elements of the criminal offense.
(4) The official conducting a hearing under this section may sanction a person, including any party or attorney, for failing to comply with an order or procedure, for failing to defend an action, or for such other misconduct as would interfere with the speedy, orderly, or fair conduct of the hearing. Such sanction shall reasonably relate to the severity and nature of the failure or misconduct. Such sanction may include—
(A) in the case of refusal to provide or permit discovery, drawing negative factual inference or treating such refusal as an admission by deeming the matter, or certain facts, to be established;
(B) prohibiting a party from introducing certain evidence or otherwise supporting a particular claim or defense;
(C) striking pleadings, in whole or in part;
(D) staying the proceedings;
(E) dismissal of the action;
(F) entering a default judgment;
(G) ordering the party or attorney to pay attorneys’ fees and other costs caused by the failure or misconduct; and
(H) refusing to consider any motion or other action which is not filed in a timely manner.
(c) Amount or scope of penalties, assessments, or exclusionsIn determining pursuant to subsection (a) the amount or scope of any penalty or assessment, or whether to recommend an exclusion, the Commissioner of Social Security shall take into account—
(1) the nature of the statements, representations, or actions referred to in subsection (a) and the circumstances under which they occurred;
(2) the degree of culpability, history of prior offenses, and financial condition of the person committing the offense; and
(3) such other matters as justice may require.
(d) Judicial review
(1) Any person adversely affected by a determination of the Commissioner of Social Security under this section may obtain a review of such determination in the United States Court of Appeals for the circuit in which the person resides, or in which the statement or representation referred to in subsection (a) was made, by filing in such court (within 60 days following the date the person is notified of the Commissioner’s determination) a written petition requesting that the determination be modified or set aside. A copy of the petition shall be forthwith transmitted by the clerk of the court to the Commissioner of Social Security, and thereupon the Commissioner of Social Security shall file in the court the record in the proceeding as provided in section 2112 of title 28. Upon such filing, the court shall have jurisdiction of the proceeding and of the question determined therein, and shall have the power to make and enter upon the pleadings, testimony, and proceedings set forth in such record a decree affirming, modifying, remanding for further consideration, or setting aside, in whole or in part, the determination of the Commissioner of Social Security and enforcing the same to the extent that such order is affirmed or modified. No objection that has not been urged before the Commissioner of Social Security shall be considered by the court, unless the failure or neglect to urge such objection shall be excused because of extraordinary circumstances.
(2) The findings of the Commissioner of Social Security with respect to questions of fact, if supported by substantial evidence on the record considered as a whole, shall be conclusive in the review described in paragraph (1). If any party shall apply to the court for leave to adduce additional evidence and shall show to the satisfaction of the court that such additional evidence is material and that there were reasonable grounds for the failure to adduce such evidence in the hearing before the Commissioner of Social Security, the court may order such additional evidence to be taken before the Commissioner of Social Security and to be made a part of the record. The Commissioner of Social Security may modify such findings as to the facts, or make new findings, by reason of additional evidence so taken and filed, and the Commissioner of Social Security shall file with the court such modified or new findings, which findings with respect to questions of fact, if supported by substantial evidence on the record considered as a whole shall be conclusive, and the Commissioner’s recommendations, if any, for the modification or setting aside of the Commissioner’s original order.
(3) Upon the filing of the record and the Commissioner’s original or modified order with the court, the jurisdiction of the court shall be exclusive and its judgment and decree shall be final, except that the same shall be subject to review by the Supreme Court of the United States, as provided in section 1254 of title 28.
(e) Compromise of money penalties and assessments; recovery; use of funds recovered
(1) Civil money penalties and assessments imposed under this section may be compromised by the Commissioner of Social Security and may be recovered—
(A) in a civil action in the name of the United States brought in United States district court for the district where the violation occurred, or where the person resides, as determined by the Commissioner of Social Security;
(B) by means of reduction in tax refunds to which the person is entitled, based on notice to the Secretary of the Treasury as permitted under section 3720A of title 31;
(C)
(i) by decrease of any payment of monthly insurance benefits under subchapter II, notwithstanding section 407 of this title,
(ii) by decrease of any payment under subchapter VIII to which the person is entitled, or
(iii) by decrease of any payment under subchapter XVI for which the person is eligible, notwithstanding section 407 of this title, as made applicable to subchapter XVI by reason of section 1383(d)(1) of this title;
(D) by authorities provided under the Debt Collection Act of 1982, as amended, to the extent applicable to debts arising under this chapter;
(E) by deduction of the amount of such penalty or assessment, when finally determined, or the amount agreed upon in compromise, from any sum then or later owing by the United States to the person against whom the penalty or assessment has been assessed; or
(F) by any combination of the foregoing.
(2) Amounts recovered under this section shall be recovered by the Commissioner of Social Security and shall be disposed of as follows:
(A) In the case of amounts recovered arising out of a determination relating to subchapter II, the amounts shall be transferred to the Managing Trustee of the Federal Old-Age and Survivors Insurance Trust Fund or the Federal Disability Insurance Trust Fund, as determined appropriate by the Commissioner of Social Security, and such amounts shall be deposited by the Managing Trustee into such Trust Fund.
(B) In the case of any other amounts recovered under this section, the amounts shall be deposited by the Commissioner of Social Security into the general fund of the Treasury as miscellaneous receipts.
(f) Finality of determination respecting penalty, assessment, or exclusion
(g) Notification of appropriate entities of finality of determination
(h) Injunction
(i) Delegation of authority
(1) The provisions of subsections (d) and (e) of section 405 of this title shall apply with respect to this section to the same extent as they are applicable with respect to subchapter II. The Commissioner of Social Security may delegate the authority granted by section 405(d) of this title (as made applicable to this section) to the Inspector General for purposes of any investigation under this section.
(2) The Commissioner of Social Security may delegate authority granted under this section to the Inspector General.
(j) “State agency” defined
(k) Liability of principal for acts of agents
(l) Protection of ongoing criminal investigations
(Aug. 14, 1935, ch. 531, title XI, § 1129, as added and amended Pub. L. 103–296, title I, § 108(b)(10)(A), title II, § 206(b)(1), (e)(1), Aug. 15, 1994, 108 Stat. 1483, 1509, 1515; Pub. L. 106–169, title II, § 251(b)(6), Dec. 14, 1999, 113 Stat. 1855; Pub. L. 108–203, title I, § 111(a), title II, § 201(a)(1), (b), (c), Mar. 2, 2004, 118 Stat. 507, 508; Pub. L. 114–74, title VIII, § 813(c), Nov. 2, 2015, 129 Stat. 603.)

CITE AS: 42 USC 1320a-8

§ 1320a–8a. Administrative procedure for imposing penalties for false or misleading statements
(a) In general
Any person who—
(1) makes, or causes to be made, a statement or representation of a material fact, for use in determining any initial or continuing right to or the amount of monthly insurance benefits under subchapter II or benefits or payments under subchapter XVI that the person knows or should know is false or misleading,
(2) makes such a statement or representation for such use with knowing disregard for the truth, or
(3) omits from a statement or representation for such use, or otherwise withholds disclosure of, a fact which the person knows or should know is material to the determination of any initial or continuing right to or the amount of monthly insurance benefits under subchapter II or benefits or payments under subchapter XVI, if the person knows, or should know, that the statement or representation with such omission is false or misleading or that the withholding of such disclosure is misleading,
shall be subject to, in addition to any other penalties that may be prescribed by law, a penalty described in subsection (b) to be imposed by the Commissioner of Social Security.
(b) Penalty
The penalty described in this subsection is—
(1) nonpayment of benefits under subchapter II that would otherwise be payable to the person; and
(2) ineligibility for cash benefits under subchapter XVI,
for each month that begins during the applicable period described in subsection (c).
(c) Duration of penalty
The duration of the applicable period, with respect to a determination by the Commissioner under subsection (a) that a person has engaged in conduct described in subsection (a), shall be—
(1) six consecutive months, in the case of the first such determination with respect to the person;
(2) twelve consecutive months, in the case of the second such determination with respect to the person; and
(3) twenty-four consecutive months, in the case of the third or subsequent such determination with respect to the person.
(d) Effect on other assistance
A person subject to a period of nonpayment of benefits under subchapter II or ineligibility for subchapter XVI benefits by reason of this section nevertheless shall be considered to be eligible for and receiving such benefits, to the extent that the person would be receiving or eligible for such benefits but for the imposition of the penalty, for purposes of—
(1) determination of the eligibility of the person for benefits under subchapters XVIII and XIX; and
(2) determination of the eligibility or amount of benefits payable under subchapter II or XVI to another person.
(e) Definition
(f) Consultations
(Aug. 14, 1935, ch. 531, title XI, § 1129A, as added Pub. L. 106–169, title II, § 207(a), Dec. 14, 1999, 113 Stat. 1837; amended Pub. L. 106–554, § 1(a)(1) [title V, § 518(b)(2)], Dec. 21, 2000, 114 Stat. 2763, 2763A–74; Pub. L. 108–203, title II, § 201(a)(2), Mar. 2, 2004, 118 Stat. 508.)

CITE AS: 42 USC 1320a-8a

§ 1320a–8b. Attempts to interfere with administration of this chapter

Whoever corruptly or by force or threats of force (including any threatening letter or communication) attempts to intimidate or impede any officer, employee, or contractor of the Social Security Administration (including any State employee of a disability determination service or any other individual designated by the Commissioner of Social Security) acting in an official capacity to carry out a duty under this chapter, or in any other way corruptly or by force or threats of force (including any threatening letter or communication) obstructs or impedes, or attempts to obstruct or impede, the due administration of this chapter, shall be fined not more than $5,000, imprisoned not more than 3 years, or both, except that if the offense is committed only by threats of force, the person shall be fined not more than $3,000, imprisoned not more than 1 year, or both. In this subsection, the term “threats of force” means threats of harm to the officer or employee of the United States or to a contractor of the Social Security Administration, or to a member of the family of such an officer or employee or contractor.

(Aug. 14, 1935, ch. 531, title XI, § 1129B, as added Pub. L. 108–203, title II, § 206, Mar. 2, 2004, 118 Stat. 512.)

CITE AS: 42 USC 1320a-8b

§ 1320a–9. Demonstration projects
(a) Authority to approve demonstration projects
(1) In general
(2) Limitation
(3) Conditions for State eligibilityFor purposes of a new demonstration project under this section that is initially approved in any of fiscal years 2012 through 2014, a State shall be authorized to conduct such demonstration project only if the State satisfies the following conditions:
(A) Identify 1 or more goals
(i) In generalThe State shall demonstrate that the demonstration project is designed to accomplish 1 or more of the following goals:(I) Increase permanency for all infants, children, and youth by reducing the time in foster placements when possible and promoting a successful transition to adulthood for older youth.(II) Increase positive outcomes for infants, children, youth, and families in their homes and communities, including tribal communities, and improve the safety and well-being of infants, children, and youth.(III) Prevent child abuse and neglect and the re-entry of infants, children, and youth into foster care.
(ii) Long-term therapeutic family treatment centers; addressing domestic violenceWith respect to a demonstration project that is designed to accomplish 1 or more of the goals described in clause (i), the State may elect to establish a program—(I) to permit foster care maintenance payments to be made under part E of subchapter IV to a long-term therapeutic family treatment center (as described in paragraph (8)(B)) on behalf of a child residing in the center; or(II) to identify and address domestic violence that endangers children and results in the placement of children in foster care.
(B) Demonstrate readiness
(C) Demonstrate implemented or planned child welfare program improvement policies
(i) In general
(ii) Previous implementation
(iii) Implementation review
(4) Limitation on eligibility
(5) Requirement to consider effect of project on terms and conditions of certain court orders
(6) Inapplicability of random assignment for control groups as a factor for approval of demonstration projects
(7) Child welfare program improvement policiesFor purposes of paragraph (3)(C), the child welfare program improvement policies described in this paragraph are the following:
(A) The establishment of a bill of rights for infants, children, and youth in foster care that is widely shared and clearly outlines protections for infants, children, and youth, such as assuring frequent visits with parents, siblings, and caseworkers, access to attorneys, and participation in age-appropriate extracurricular activities, and procedures for ensuring the protections are provided.
(B) The development and implementation of a plan for meeting the health and mental health needs of infants, children, and youth in foster care that includes ensuring that the provision of health and mental health care is child-specific, comprehensive, appropriate, and consistent (through means such as ensuring the infant, child, or youth has a medical home, regular wellness medical visits, and addressing the issue of trauma, when appropriate).
(C) The inclusion in the State plan under section 671 of this title of an amendment implementing the option under subsection (a)(28) of that section to enter into kinship guardianship assistance agreements.
(D) The election under the State plan under section 671 of this title to define a “child” for purposes of the provision of foster care maintenance payments, adoption assistance payments, and kinship guardianship assistance payments, so as to include individuals described in each of subclauses (I), (II), and (III) of section 675(8)(B)(i) of this title who have not attained age 21.
(E) The development and implementation of a plan that ensures congregate care is used appropriately and reduces the placement of children and youth in such care.
(F) Of those infants, children, and youth in out-of-home placements, substantially increasing the number of cases of siblings who are in the same foster care, kinship guardianship, or adoptive placement, above the number of such cases in fiscal year 2008.
(G) The development and implementation of a plan to improve the recruitment and retention of high quality foster family homes trained to help assist infants, children, and youth swiftly secure permanent families. Supports for foster families under such a plan may include increasing maintenance payments to more adequately meet the needs of infants, children, and youth in foster care and expanding training, respite care, and other support services for foster parents.
(H) The establishment of procedures designed to assist youth as they prepare for their transition out of foster care, such as arranging for participation in age-appropriate extra-curricular activities, providing appropriate access to cell phones, computers, and opportunities to obtain a driver’s license, providing notification of all sibling placements if siblings are in care and sibling location if siblings are out of care, and providing counseling and financial support for post-secondary education.
(I) The inclusion in the State plan under section 671 of this title of a description of State procedures for—
(i) ensuring that youth in foster care who have attained age 16 are engaged in discussions, including during the development of the transition plans required under paragraphs (1)(D) and (5)(H) of section 675 of this title, that explore whether the youth wishes to reconnect with the youth’s biological family, including parents, grandparents, and siblings, and, if so, what skills and strategies the youth will need to successfully and safely reconnect with those family members;
(ii) providing appropriate guidance and services to youth whom 1
1 So in original. Probably should be “who”.
affirm an intent to reconnect with biological family members on how to successfully and safely manage such reconnections; and
(iii) making, when appropriate, efforts to include biological family members in such reconnection efforts.
(J) The establishment of one or more of the following programs designed to prevent infants, children, and youth from entering foster care or to provide permanency for infants, children, and youth in foster care:
(i) An intensive family finding program.
(ii) A kinship navigator program.
(iii) A family counseling program, such as a family group decision-making program, and which may include in-home peer support for families.
(iv) A comprehensive family-based substance abuse treatment program.
(v) A program under which special efforts are made to identify and address domestic violence that endangers infants, children, and youth and puts them at risk of entering foster care.
(vi) A mentoring program.
(8) DefinitionsIn this subsection—
(A) the term “youth” means, with respect to a State, an individual who has attained age 12 but has not attained the age at which an individual is no longer considered to be a child under the State plans under parts B and E of subchapter IV, and
(B) the term “long-term therapeutic family treatment center” means a State licensed or certified program that enables parents and their children to live together in a safe environment for a period of not less than 6 months and provides, on-site or by referral, substance abuse treatment services, children’s early intervention services, family counseling, legal services, medical care, mental health services, nursery and preschool, parenting skills training, pediatric care, prenatal care, sexual abuse therapy, relapse prevention, transportation, and job or vocational training or classes leading to a secondary school diploma or a certificate of general equivalence.
(b) Waiver authorityThe Secretary may waive compliance with any requirement of part B or E of subchapter IV which (if applied) would prevent a State from carrying out a demonstration project under this section or prevent the State from effectively achieving the purpose of such a project, except that the Secretary may not waive—
(1) any provision of section 622(b)(8) of this title, or section 679 of this title; or
(2) any provision of such part E, to the extent that the waiver would impair the entitlement of any qualified child or family to benefits under a State plan approved under such part E.
(c) Treatment as program expenditures
(d) Duration of demonstration
(1) In general
(2) Termination of authority
(e) ApplicationAny State seeking to conduct a demonstration project under this section shall submit to the Secretary an application, in such form as the Secretary may require, which includes—
(1) a description of the proposed project, the geographic area in which the proposed project would be conducted, the children or families who would be served by the proposed project, and the services which would be provided by the proposed project;
(2) a statement of the period during which the proposed project would be conducted;
(3) a discussion of the benefits that are expected from the proposed project (compared to a continuation of activities under the approved plan or plans of the State);
(4) an estimate of the costs or savings of the proposed project;
(5) a statement of program requirements for which waivers would be needed to permit the proposed project to be conducted;
(6) a description of the proposed evaluation design;
(7) an accounting of any additional Federal, State, and local investments made, as well as any private investments made in coordination with the State, during the 2 fiscal years preceding the application to provide the services described in paragraph (1), and an assurance that the State will provide an accounting of that same spending for each year of an approved demonstration project; and
(8) such additional information as the Secretary may require.
(f) EvaluationsEach State authorized to conduct a demonstration project under this section shall obtain an evaluation by an independent contractor of the effectiveness of the project, using an evaluation design approved by the Secretary which provides for—
(1) comparison of methods of service delivery under the project, and such methods under a State plan or plans, with respect to efficiency, economy, and any other appropriate measures of program management;
(2) comparison of outcomes for children and families (and groups of children and families) under the project, and such outcomes under a State plan or plans, for purposes of assessing the effectiveness of the project in achieving program goals; and
(3) any other information that the Secretary may require.
(g) Reports
(1) State reports; public availabilityEach State authorized to conduct a demonstration project under this section shall—
(A) submit periodic reports to the Secretary on the specific programs, activities, and strategies used to improve outcomes for infants, children, youth, and families and the results achieved for infants, children, and youth during the conduct of the demonstration project, including with respect to those infants, children, and youth who are prevented from entering foster care, infants, children, and youth in foster care, and infants, children, and youth who move from foster care to permanent families; and
(B) post a copy of each such report on the website for the State child welfare program concurrent with the submission of the report to the Secretary.
(2) Reports to CongressThe Secretary shall submit to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate—
(A) periodic reports based on the State reports submitted under paragraph (1); and
(B) a report based on the results of the State evaluations required under subsection (f) that includes an analysis of the results of such evaluations and such recommendations for administrative or legislative changes as the Secretary determines appropriate.
(h) Cost neutrality
(i) Indian tribes operating IV–E programs considered States
(Aug. 14, 1935, ch. 531, title XI, § 1130, as added Pub. L. 103–432, title II, § 208, Oct. 31, 1994, 108 Stat. 4457; amended Pub. L. 105–89, title III, § 301(a), (c), Nov. 19, 1997, 111 Stat. 2127, 2128; Pub. L. 108–40, § 5, June 30, 2003, 117 Stat. 837; Pub. L. 109–288, § 6(f)(8), Sept. 28, 2006, 120 Stat. 1248; Pub. L. 112–34, title II, § 201, Sept. 30, 2011, 125 Stat. 378.)

CITE AS: 42 USC 1320a-9

§ 1320a–10. Effect of failure to carry out State plan

In an action brought to enforce a provision of this chapter, such provision is not to be deemed unenforceable because of its inclusion in a section of this chapter requiring a State plan or specifying the required contents of a State plan. This section is not intended to limit or expand the grounds for determining the availability of private actions to enforce State plan requirements other than by overturning any such grounds applied in Suter v. Artist M., 112 S. Ct. 1360 (1992), but not applied in prior Supreme Court decisions respecting such enforceability: Provided, however, That this section is not intended to alter the holding in Suter v. Artist M. that section 671(a)(15) of this title is not enforceable in a private right of action.

(Aug. 14, 1935, ch. 531, title XI, § 1130A, as added Pub. L. 103–432, title II, § 211(a), Oct. 31, 1994, 108 Stat. 4460.)

CITE AS: 42 USC 1320a-10

§ 1320b. Repealed. Pub. L. 93–647, § 3(e)(1), Jan. 4, 1975, 88 Stat. 2349

CITE AS: 42 USC 1320b

§ 1320b–1. Notification of Social Security claimant with respect to deferred vested benefits
(a) Whenever—
(1) the Commissioner of Social Security makes a finding of fact and a decision as to—
(A) the entitlement of any individual to monthly benefits under section 402, 423, or 428 of this title, or
(B) the entitlement of any individual to a lump-sum death payment payable under section 402(i) of this title on account of the death of any person to whom such individual is related by blood, marriage, or adoption,
(2) the Secretary makes a finding of fact and a decision as to the entitlement under section 426 of this title of any individual to hospital insurance benefits under part A of subchapter XVIII, or
(3) the Commissioner of Social Security is requested to do so—
(A) by any individual with respect to whom the Commissioner of Social Security holds information obtained under section 6057 of the Internal Revenue Code of 1986, or
(B) in the case of the death of the individual referred to in subparagraph (A), by the individual who would be entitled to payment under section 404(d) of this title,
the Commissioner of Social Security shall transmit to the individual referred to in paragraph (1) or (2) or the individual making the request under paragraph (3) any information, as reported by the employer, regarding any deferred vested benefit transmitted to the Commissioner of Social Security pursuant to such section 6057 with respect to the individual referred to in paragraph (1), (2), or (3)(A) or the person on whose wages and self-employment income entitlement (or claim of entitlement) is based.
(b)
(1) For purposes of section 401(g)(1) of this title, expenses incurred in the administration of subsection (a) shall be deemed to be expenses incurred for the administration of subchapter II.
(2) There are hereby authorized to be appropriated to the Federal Old-Age and Survivors Insurance Trust Fund for each fiscal year (commencing with the fiscal year ending June 30, 1974) such sums as the Commissioner of Social Security deems necessary on account of additional administrative expenses resulting from the enactment of the provisions of subsection (a).
(Aug. 14, 1935, ch. 531, title XI, § 1131, as added Pub. L. 93–406, title II, § 1032, Sept. 2, 1974, 88 Stat. 947; amended Pub. L. 98–369, div. B, title VI, § 2663(e)(7), July 18, 1984, 98 Stat. 1168; Pub. L. 99–514, § 2, Oct. 22, 1986, 100 Stat. 2095; Pub. L. 103–296, title I, § 108(b)(11), Aug. 15, 1994, 108 Stat. 1484.)

CITE AS: 42 USC 1320b-1

§ 1320b–2. Period within which certain claims must be filed
(a) Claims
Notwithstanding any other provision of this chapter (but subject to subsection (b)), any claim by a State for payment with respect to an expenditure made during any calendar quarter by the State—
(1) in carrying out a State plan approved under subchapter I, IV, X, XIV, XVI, XIX, or XX of this chapter, or
(2) under any other provision of this chapter which provides (on an entitlement basis) for Federal financial participation in expenditures made under State plans or programs,
shall be filed (in such form and manner as the Secretary shall by regulations prescribe) within the two-year period which begins on the first day of the calendar quarter immediately following such calendar quarter; and payment shall not be made under this chapter on account of any such expenditure if claim therefor is not made within such two-year period; except that this subsection shall not be applied so as to deny payment with respect to any expenditure involving court-ordered retroactive payments or audit exceptions, or adjustments to prior year costs.
(b) Waiver
(Aug. 14, 1935, ch. 531, title XI, § 1132, as added Pub. L. 96–272, title III, § 306(a), June 17, 1980, 94 Stat. 530; amended Pub. L. 97–35, title XXI, § 2193(c)(5), Aug. 13, 1981, 95 Stat. 827.)

CITE AS: 42 USC 1320b-2

§ 1320b–3. Applicants or recipients under public assistance programs not to be required to make election respecting certain veterans’ benefits
(a) Supplemental Security Income program
Notwithstanding any other provision of law (but subject to subsection (b)), no individual who is an applicant for or recipient of aid or assistance under a State plan approved under subchapter I, X, XIV, or XVI, or of benefits under the Supplemental Security Income program established by subchapter XVI shall—
(1) be required, as a condition of eligibility for (or of continuing to receive) such aid, assistance, or benefits, to make an election under section 306 of the Veterans’ and Survivors’ Pension Improvement Act of 1978 with respect to pension paid by the Secretary of Veterans Affairs, or
(2) by reason of failure or refusal to make such an election, be denied (or suffer a reduction in the amount of) such aid, assistance, or benefits.
(b) Period of effectiveness
The provisions of subsection (a) shall be applicable only with respect to an individual, who is an applicant for or recipient of aid, assistance, or benefits described in subsection (a), during a period with respect to which there is in effect—
(1) in case such individual is an applicant for or recipient of aid or assistance under a State plan referred to in subsection (a), in the State having such plan, or
(2) in case such individual is an applicant for or recipient of benefits under the Supplemental Security Income program established by subchapter XVI, in the State in which the individual applies for or receives such benefits,
a State plan for medical assistance, approved under subchapter XIX, under which medical assistance is available to such individual only for periods for which such individual is a recipient of aid, assistance, or benefits described in subsection (a).
(Aug. 14, 1935, ch. 531, title XI, § 1133, as added Pub. L. 96–272, title III, § 310(a)(1), June 17, 1980, 94 Stat. 532; amended Pub. L. 102–54, § 13(q)(3)(B)(iii), June 13, 1991, 105 Stat. 279; Pub. L. 104–193, title I, § 108(g)(6), Aug. 22, 1996, 110 Stat. 2168.)

CITE AS: 42 USC 1320b-3

§ 1320b–4. Nonprofit hospital or critical access hospital philanthropy
For purposes of determining, under subchapters XVIII and XIX of this chapter, the reasonable costs of services provided by nonprofit hospitals or critical access hospitals, the following items shall not be deducted from the operating costs of such hospitals or critical access hospitals:
(1) A grant, gift, or endowment, or income therefrom, which is to or for such a hospital and which has not been designated by the donor for paying any specific operating costs.
(2) A grant or similar payment which is to such a hospital, which was made by a governmental entity, and which is not available under the terms of the grant or payment for use as operating funds.
(3) Those types of donor designated grants and gifts (including grants and similar payments which are made by a governmental entity), and income therefrom, which the Secretary determines, in the best interests of needed health care, should be encouraged.
(4) The proceeds from the sale or mortgage of any real estate or other capital asset of such a hospital, which real estate or asset the hospital acquired through gift or grant, if such proceeds are not available for use as operating funds under the terms of the gift or grant.
Paragraph (4) shall not apply to the recovery of the appropriate share of depreciation when gains or losses are realized from the disposal of depreciable assets.
(Aug. 14, 1935, ch. 531, title XI, § 1134, as added Pub. L. 96–499, title IX, § 901(a), Dec. 5, 1980, 94 Stat. 2611; amended Pub. L. 97–35, title XXI, § 2193(c)(6), Aug. 13, 1981, 95 Stat. 827; Pub. L. 97–248, title I, § 137(b)(5), Sept. 3, 1982, 96 Stat. 377; Pub. L. 101–239, title VI, § 6003(g)(3)(D)(iii), Dec. 19, 1989, 103 Stat. 2153; Pub. L. 105–33, title IV, § 4201(c)(1), Aug. 5, 1997, 111 Stat. 373.)

CITE AS: 42 USC 1320b-4

§ 1320b–5. Authority to waive requirements during national emergencies
(a) PurposeThe purpose of this section is to enable the Secretary to ensure to the maximum extent feasible, in any emergency area and during an emergency period (as defined in subsection (g)(1))—
(1) that sufficient health care items and services are available to meet the needs of individuals in such area enrolled in the programs under subchapters XVIII, XIX, and XXI; and
(2) that health care providers (as defined in subsection (g)(2)) that furnish such items and services in good faith, but that are unable to comply with one or more requirements described in subsection (b), may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse.
(b) Secretarial authorityTo the extent necessary to accomplish the purpose specified in subsection (a), the Secretary is authorized, subject to the provisions of this section, to temporarily waive or modify the application of, with respect to health care items and services furnished by a health care provider (or classes of health care providers) in any emergency area (or portion of such an area) during any portion of an emergency period, the requirements of subchapters XVIII, XIX, or XXI, or any regulation thereunder (and the requirements of this subchapter other than this section, and regulations thereunder, insofar as they relate to such subchapters), pertaining to—
(1)
(A) conditions of participation or other certification requirements for an individual health care provider or types of providers,
(B) program participation and similar requirements for an individual health care provider or types of providers, and
(C) pre-approval requirements;
(2) requirements that physicians and other health care professionals be licensed in the State in which they provide such services, if they have equivalent licensing in another State and are not affirmatively excluded from practice in that State or in any State a part of which is included in the emergency area;
(3) actions under section 1395dd of this title (relating to examination and treatment for emergency medical conditions and women in labor) for—
(A) a transfer of an individual who has not been stabilized in violation of subsection (c) of such section if the transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period; or
(B) the direction or relocation of an individual to receive medical screening in an alternative location—
(i) pursuant to an appropriate State emergency preparedness plan; or
(ii) in the case of a public health emergency described in subsection (g)(1)(B) that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan or a plan referred to in clause (i), whichever is applicable in the State;
(4) sanctions under section 1395nn(g) of this title (relating to limitations on physician referral);
(5) deadlines and timetables for performance of required activities, except that such deadlines and timetables may only be modified, not waived;
(6) limitations on payments under section 1395w–21(i) of this title for health care items and services furnished to individuals enrolled in a Medicare+Choice plan by health care professionals or facilities not included under such plan;
(7) sanctions and penalties that arise from noncompliance with the following requirements (as promulgated under the authority of section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note)— 1
1 So in original. A second closing parenthesis probably should precede the dash.
(A) section 164.510 of title 45, Code of Federal Regulations, relating to—
(i) requirements to obtain a patient’s agreement to speak with family members or friends; and
(ii) the requirement to honor a request to opt out of the facility directory;
(B) section 164.520 of such title, relating to the requirement to distribute a notice; or
(C) section 164.522 of such title, relating to—
(i) the patient’s right to request privacy restrictions; and
(ii) the patient’s right to request confidential communications;
(8) in the case of a telehealth service (as defined in paragraph (4)(F) of section 1395m(m) of this title) furnished in any emergency area (or portion of such an area) during any portion of any emergency period, the requirements of section 1395m(m) of this title; and
(9) any requirement under section 1395x(s)(7) of this title or section 1395m(l) of this title that an ambulance service include the transport of an individual to the extent necessary to allow payment for ground ambulance services furnished in response to a 911 call (or the equivalent in areas without a 911 call system) in cases in which an individual would have been transported to a destination permitted under Medicare regulations (as described in section 410.40 to title 42, Code of Federal Regulations (or successor regulations)) but such transport did not occur as a result of community-wide emergency medical service (EMS) protocols due to the public health emergency described in subsection (g)(1)(B).
Insofar as the Secretary exercises authority under paragraph (6) with respect to individuals enrolled in a Medicare+Choice plan, to the extent possible given the circumstances, the Secretary shall reconcile payments made on behalf of such enrollees to ensure that the enrollees do not pay more than would be required had they received services from providers within the network of the plan and may reconcile payments to the organization offering the plan to ensure that such organization pays for services for which payment is included in the capitation payment it receives under part C of subchapter XVIII. A waiver or modification provided for under paragraph (3) or (7) shall only be in effect if such actions are taken in a manner that does not discriminate among individuals on the basis of their source of payment or of their ability to pay, and, except in the case of a waiver or modification to which the fifth sentence of this subsection applies, shall be limited to a 72-hour period beginning upon implementation of a hospital disaster protocol. A waiver or modification under such paragraph (7) shall be withdrawn after such period and the provider shall comply with the requirements under such paragraph for any patient still under the care of the provider. If a public health emergency described in subsection (g)(1)(B) involves a pandemic infectious disease (such as pandemic influenza), the duration of a waiver or modification under paragraph (3) shall be determined in accordance with subsection (e) as such subsection applies to public health emergencies. Ground ambulance services for which payment is made pursuant to paragraph (9) shall be paid at the base rate that would have been paid under the fee schedule established under 2
2 So in original. The word “section” probably should appear.
1395m(l
(c) Authority for retroactive waiver
(d) Certification to CongressThe Secretary shall provide a certification and advance written notice to the Congress at least two days before exercising the authority under this section with respect to an emergency area. Such a certification and notice shall include—
(1) a description of—
(A) the specific provisions that will be waived or modified;
(B) the health care providers to whom the waiver or modification will apply;
(C) the geographic area in which the waiver or modification will apply; and
(D) the period of time for which the waiver or modification will be in effect; and
(2) a certification that the waiver or modification is necessary to carry out the purpose specified in subsection (a).
(e) Duration of waiver
(1) In generalA waiver or modification of requirements pursuant to this section terminates upon—
(A) the termination of the applicable declaration of emergency or disaster described in subsection (g)(1)(A);
(B) the termination of the applicable declaration of public health emergency described in subsection (g)(1)(B); or
(C) subject to paragraph (2), the termination of a period of 60 days from the date the waiver or modification is first published (or, if applicable, the date of extension of the waiver or modification under paragraph (2)).
(2) Extension of 60-day periods
(f) Report to Congress
(g) DefinitionsFor purposes of this section:
(1) Emergency area; emergency period
(A) In generalSubject to subparagraph (B), an “emergency area” is a geographical area in which, and an “emergency period” is the period during which, there exists—
(i) an emergency or disaster declared by the President pursuant to the National Emergencies Act [50 U.S.C. 1601 et seq.] or the Robert T. Stafford Disaster Relief and Emergency Assistance Act [42 U.S.C. 5121 et seq.]; and
(ii) a public health emergency declared by the Secretary pursuant to section 247d of this title.
(B) ExceptionFor purposes of paragraphs (8) and (9) of subsection (b), an “emergency area” is a geographical area in which, and an “emergency period” is the period during which, there exists—
(i) the public health emergency declared by the Secretary pursuant to section 247d of this title on January 31, 2020, entitled “Determination that a Public Health Emergency Exists Nationwide as the Result of the 2019 Novel Coronavirus”; and
(ii) any renewal of such declaration pursuant to such section 247d of this title.
(2) Health care provider
(Aug. 14, 1935, ch. 531, title XI, § 1135, as added Pub. L. 107–188, title I, § 143(a), June 12, 2002, 116 Stat. 627; amended Pub. L. 108–276, § 9, July 21, 2004, 118 Stat. 863; Pub. L. 109–417, title III, § 302(b)(1), Dec. 19, 2006, 120 Stat. 2855; Pub. L. 116–123, div. B, § 102(a)(1), (2), (b), Mar. 6, 2020, 134 Stat. 156; Pub. L. 116–127, div. F, § 6010, Mar. 18, 2020, 134 Stat. 210; Pub. L. 116–136, div. A, title III, § 3703, Mar. 27, 2020, 134 Stat. 416; Pub. L. 117–2, title IX, § 9832, Mar. 11, 2021, 135 Stat. 222.)

CITE AS: 42 USC 1320b-5

§ 1320b–6. Exclusion of representatives and health care providers convicted of violations from participation in social security programs
(a) In generalThe Commissioner of Social Security shall exclude from participation in the social security programs any representative or health care provider—
(1) who is convicted of a violation of section 408 or 1383a of this title;
(2) who is convicted of any violation under title 18 relating to an initial application for or continuing entitlement to, or amount of, benefits under subchapter II of this chapter, or an initial application for or continuing eligibility for, or amount of, benefits under subchapter XVI of this chapter; or
(3) who the Commissioner determines has committed an offense described in section 1320a–8(a)(1) of this title.
(b) Notice, effective date, and period of exclusion
(1) An exclusion under this section shall be effective at such time, for such period, and upon such reasonable notice to the public and to the individual excluded as may be specified in regulations consistent with paragraph (2).
(2) Such an exclusion shall be effective with respect to services furnished to any individual on or after the effective date of the exclusion. Nothing in this section may be construed to preclude, in determining disability under subchapter II or subchapter XVI, consideration of any medical evidence derived from services provided by a health care provider before the effective date of the exclusion of the health care provider under this section.
(3)
(A) The Commissioner shall specify, in the notice of exclusion under paragraph (1), the period of the exclusion.
(B) Subject to subparagraph (C), in the case of an exclusion under subsection (a), the minimum period of exclusion shall be 5 years, except that the Commissioner may waive the exclusion in the case of an individual who is the sole source of essential services in a community. The Commissioner’s decision whether to waive the exclusion shall not be reviewable.
(C) In the case of an exclusion of an individual under subsection (a) based on a conviction or a determination described in subsection (a)(3) occurring on or after December 14, 1999, if the individual has (before, on, or after December 14, 1999) been convicted, or if such a determination has been made with respect to the individual—
(i) on one previous occasion of one or more offenses for which an exclusion may be effected under such subsection, the period of the exclusion shall be not less than 10 years; or
(ii) on two or more previous occasions of one or more offenses for which an exclusion may be effected under such subsection, the period of the exclusion shall be permanent.
(c) Notice to State agenciesThe Commissioner shall promptly notify each appropriate State agency employed for the purpose of making disability determinations under section 421 or 1383b(a) of this title—
(1) of the fact and circumstances of each exclusion effected against an individual under this section; and
(2) of the period (described in subsection (b)(3)) for which the State agency is directed to exclude the individual from participation in the activities of the State agency in the course of its employment.
(d) Notice to State licensing agenciesThe Commissioner shall—
(1) promptly notify the appropriate State or local agency or authority having responsibility for the licensing or certification of an individual excluded from participation under this section of the fact and circumstances of the exclusion;
(2) request that appropriate investigations be made and sanctions invoked in accordance with applicable State law and policy; and
(3) request that the State or local agency or authority keep the Commissioner and the Inspector General of the Social Security Administration fully and currently informed with respect to any actions taken in response to the request.
(e) Notice, hearing, and judicial review
(1) Any individual who is excluded (or directed to be excluded) from participation under this section is entitled to reasonable notice and opportunity for a hearing thereon by the Commissioner to the same extent as is provided in section 405(b) of this title, and to judicial review of the Commissioner’s final decision after such hearing as is provided in section 405(g) of this title.
(2) The provisions of section 405(h) of this title shall apply with respect to this section to the same extent as it is applicable with respect to subchapter II.
(f) Application for termination of exclusion
(1) An individual excluded from participation under this section may apply to the Commissioner, in the manner specified by the Commissioner in regulations and at the end of the minimum period of exclusion provided under subsection (b)(3) and at such other times as the Commissioner may provide, for termination of the exclusion effected under this section.
(2) The Commissioner may terminate the exclusion if the Commissioner determines, on the basis of the conduct of the applicant which occurred after the date of the notice of exclusion or which was unknown to the Commissioner at the time of the exclusion, that—
(A) there is no basis under subsection (a) for a continuation of the exclusion; and
(B) there are reasonable assurances that the types of actions which formed the basis for the original exclusion have not recurred and will not recur.
(3) The Commissioner shall promptly notify each State agency employed for the purpose of making disability determinations under section 421 or 1383b(a) of this title of the fact and circumstances of each termination of exclusion made under this subsection.
(g) Availability of records of excluded representatives and health care providers
(h) Reporting requirement
(i) Delegation of authority
(j) DefinitionsFor purposes of this section:
(1) ExcludeThe term “exclude” from participation means—
(A) in connection with a representative, to prohibit from engaging in representation of an applicant for, or recipient of, benefits, as a representative payee under section 405(j) or section 1383(a)(2)(A)(ii) of this title, or otherwise as a representative, in any hearing or other proceeding relating to entitlement to benefits; and
(B) in connection with a health care provider, to prohibit from providing items or services to an applicant for, or recipient of, benefits for the purpose of assisting such applicant or recipient in demonstrating disability.
(2) Social security program
(3) ConvictedAn individual is considered to have been “convicted” of a violation—
(A) when a judgment of conviction has been entered against the individual by a Federal, State, or local court, except if the judgment of conviction has been set aside or expunged;
(B) when there has been a finding of guilt against the individual by a Federal, State, or local court;
(C) when a plea of guilty or nolo contendere by the individual has been accepted by a Federal, State, or local court; or
(D) when the individual has entered into participation in a first offender, deferred adjudication, or other arrangement or program where judgment of conviction has been withheld.
(Aug. 14, 1935, ch. 531, title XI, § 1136, as added Pub. L. 106–169, title II, § 208(a), Dec. 14, 1999, 113 Stat. 1839.)

CITE AS: 42 USC 1320b-6

§ 1320b–7. Income and eligibility verification system
(a) Requirements of State eligibility systemsIn order to meet the requirements of this section, a State must have in effect an income and eligibility verification system which meets the requirements of subsection (d) and under which—
(1) the State shall require, as a condition of eligibility for benefits under any program listed in subsection (b), that each applicant for or recipient of benefits under that program furnish to the State his social security account number (or numbers, if he has more than one such number), and the State shall utilize such account numbers in the administration of that program so as to enable the association of the records pertaining to the applicant or recipient with his account number;
(2) wage information from agencies administering State unemployment compensation laws available pursuant to section 3304(a)(16) of the Internal Revenue Code of 1986, wage information reported pursuant to paragraph (3) of this subsection, and wage, income, and other information from the Social Security Administration and the Internal Revenue Service available pursuant to section 6103(l)(7) of such Code, shall be requested and utilized to the extent that such information may be useful in verifying eligibility for, and the amount of, benefits available under any program listed in subsection (b), as determined by the Secretary of Health and Human Services (or, in the case of the unemployment compensation program, by the Secretary of Labor, or, in the case of the supplemental nutrition assistance program, by the Secretary of Agriculture);
(3) employers (as defined in section 653a(a)(2)(B) of this title) (including State and local governmental entities and labor organizations) in such State are required, effective September 30, 1988, to make quarterly wage reports to a State agency (which may be the agency administering the State’s unemployment compensation law) except that the Secretary of Labor (in consultation with the Secretary of Health and Human Services and the Secretary of Agriculture) may waive the provisions of this paragraph if he determines that the State has in effect an alternative system which is as effective and timely for purposes of providing employment related income and eligibility data for the purposes described in paragraph (2), and except that no report shall be filed with respect to an employee of a State or local agency performing intelligence or counterintelligence functions, if the head of such agency has determined that filing such a report could endanger the safety of the employee or compromise an ongoing investigation or intelligence mission, and except that in the case of wage reports with respect to domestic service employment, a State may permit employers (as so defined) that make returns with respect to such employment on a calendar year basis pursuant to section 3510 of the Internal Revenue Code of 1986 to make such reports on an annual basis;
(4) the State agencies administering the programs listed in subsection (b) adhere to standardized formats and procedures established by the Secretary of Health and Human Services (in consultation with the Secretary of Agriculture) under which—
(A) the agencies will exchange with each other information in their possession which may be of use in establishing or verifying eligibility or benefit amounts under any other such program;
(B) such information shall be made available to assist in the child support program under part D of subchapter IV of this chapter, and to assist the Secretary of Health and Human Services in establishing or verifying eligibility or benefit amounts under subchapters II and XVI of this chapter, but subject to the safeguards and restrictions established by the Secretary of the Treasury with respect to information released pursuant to section 6103(l) of the Internal Revenue Code of 1986; and
(C) the use of such information shall be targeted to those uses which are most likely to be productive in identifying and preventing ineligibility and incorrect payments, and no State shall be required to use such information to verify the eligibility of all recipients;
(5) adequate safeguards are in effect so as to assure that—
(A) the information exchanged by the State agencies is made available only to the extent necessary to assist in the valid administrative needs of the program receiving such information, and the information released pursuant to section 6103(l) of the Internal Revenue Code of 1986 is only exchanged with agencies authorized to receive such information under such section 6103(l); and
(B) the information is adequately protected against unauthorized disclosure for other purposes, as provided in regulations established by the Secretary of Health and Human Services, or, in the case of the unemployment compensation program, the Secretary of Labor, or, in the case of the supplemental nutrition assistance program, the Secretary of Agriculture, or 1
1 So in original. Probably should be followed by a comma.
in the case of information released pursuant to section 6103(l) of the Internal Revenue Code of 1986, the Secretary of the Treasury;
(6) all applicants for and recipients of benefits under any such program shall be notified at the time of application, and periodically thereafter, that information available through the system will be requested and utilized; and
(7) accounting systems are utilized which assure that programs providing data receive appropriate reimbursement from the programs utilizing the data for the costs incurred in providing the data.
(b) Applicable programsThe programs which must participate in the income and eligibility verification system are—
(1) any State program funded under part A of subchapter IV of this chapter;
(2) the medicaid program under subchapter XIX of this chapter;
(3) the unemployment compensation program under section 3304 of the Internal Revenue Code of 1986;
(4) the supplemental nutrition assistance program established under the Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.); and
(5) any State program under a plan approved under subchapter I, X, XIV, or XVI of this chapter.
(c) Protection of applicants from improper use of information
(1) In order to protect applicants for and recipients of benefits under the programs identified in subsection (b), or under the supplemental security income program under subchapter XVI, from the improper use of information obtained from the Secretary of the Treasury under section 6103(l)(7)(B) of the Internal Revenue Code of 1986, no Federal, State, or local agency receiving such information may terminate, deny, suspend, or reduce any benefits of an individual until such agency has taken appropriate steps to independently verify information relating to—
(A) the amount of the asset or income involved,
(B) whether such individual actually has (or had) access to such asset or income for his own use, and
(C) the period or periods when the individual actually had such asset or income.
(2) Such individual shall be informed by the agency of the findings made by the agency on the basis of such verified information, and shall be given an opportunity to contest such findings, in the same manner as applies to other information and findings relating to eligibility factors under the program.
(d) Citizenship or immigration status requirements; documentation; verification by Immigration and Naturalization Service; denial of benefits; hearingThe requirements of this subsection, with respect to an income and eligibility verification system of a State, are as follows:
(1)
(A) The State shall require, as a condition of an individual’s eligibility for benefits under a program listed in subsection (b), a declaration in writing, under penalty of perjury—
(i) by the individual,
(ii) in the case in which eligibility for program benefits is determined on a family or household basis, by any adult member of such individual’s family or household (as applicable), or
(iii) in the case of an individual born into a family or household receiving benefits under such program, by any adult member of such family or household no later than the next redetermination of eligibility of such family or household following the birth of such individual,
stating whether the individual is a citizen or national of the United States, and, if that individual is not a citizen or national of the United States, that the individual is in a satisfactory immigration status.
(B) In this subsection, in the case of the program described in subsection (b)(4)—
(i) any reference to the State shall be considered a reference to the State agency, and
(ii) any reference to an individual’s eligibility for benefits under the program shall be considered a reference to the individual’s eligibility to participate in the program as a member of a household, and
(iii) the term “satisfactory immigration status” means an immigration status which does not make the individual ineligible for benefits under the applicable program.
(2) If such an individual is not a citizen or national of the United States, there must be presented either—
(A) alien registration documentation or other proof of immigration registration from the Immigration and Naturalization Service that contains the individual’s alien admission number or alien file number (or numbers if the individual has more than one number), or
(B) such other documents as the State determines constitutes reasonable evidence indicating a satisfactory immigration status.
(3) If the documentation described in paragraph (2)(A) is presented, the State shall utilize the individual’s alien file or alien admission number to verify with the Immigration and Naturalization Service the individual’s immigration status through an automated or other system (designated by the Service for use with States) that—
(A) utilizes the individual’s name, file number, admission number, or other means permitting efficient verification, and
(B) protects the individual’s privacy to the maximum degree possible.
(4) In the case of such an individual who is not a citizen or national of the United States, if, at the time of application for benefits, the statement described in paragraph (1) is submitted but the documentation required under paragraph (2) is not presented or if the documentation required under paragraph (2)(A) is presented but such documentation is not verified under paragraph (3)—
(A) the State—
(i) shall provide a reasonable opportunity to submit to the State evidence indicating a satisfactory immigration status, and
(ii) may not delay, deny, reduce, or terminate the individual’s eligibility for benefits under the program on the basis of the individual’s immigration status until such a reasonable opportunity has been provided; and
(B) if there are submitted documents which the State determines constitutes reasonable evidence indicating such status—
(i) the State shall transmit to the Immigration and Naturalization Service either photostatic or other similar copies of such documents, or information from such documents, as specified by the Immigration and Naturalization Service, for official verification,
(ii) pending such verification, the State may not delay, deny, reduce, or terminate the individual’s eligibility for benefits under the program on the basis of the individual’s immigration status, and
(iii) the State shall not be liable for the consequences of any action, delay, or failure of the Service to conduct such verification.
(5) If the State determines, after complying with the requirements of paragraph (4), that such an individual is not in a satisfactory immigration status under the applicable program—
(A) the State shall deny or terminate the individual’s eligibility for benefits under the program, and
(B) the applicable fair hearing process shall be made available with respect to the individual.
(e) Erroneous State citizenship or immigration status determinations; penalties not requiredEach Federal agency responsible for administration of a program described in subsection (b) shall not take any compliance, disallowance, penalty, or other regulatory action against a State with respect to any error in the State’s determination to make an individual eligible for benefits based on citizenship or immigration status—
(1) if the State has provided such eligibility based on a verification of satisfactory immigration status by the Immigration and Naturalization Service,
(2) because the State, under subsection (d)(4)(A)(ii), was required to provide a reasonable opportunity to submit documentation,
(3) because the State, under subsection (d)(4)(B)(ii), was required to wait for the response of the Immigration and Naturalization Service to the State’s request for official verification of the immigration status of the individual, or
(4) because of a fair hearing process described in subsection (d)(5)(B).
(f) Medical assistance to aliens for treatment of emergency conditions
(Aug. 14, 1935, ch. 531, title XI, § 1137, as added Pub. L. 98–369, div. B, title VI, § 2651(a), July 18, 1984, 98 Stat. 1147; amended Pub. L. 99–509, title IX, § 9101, Oct. 21, 1986, 100 Stat. 1972; Pub. L. 99–514, § 2, Oct. 22, 1986, 100 Stat. 2095; Pub. L. 99–603, title I, § 121(a)(1), Nov. 6, 1986, 100 Stat. 3384; Pub. L. 100–360, title IV, § 411(k)(15)(A), July 1, 1988, 102 Stat. 799; Pub. L. 103–432, title II, § 231, Oct. 31, 1994, 108 Stat. 4462; Pub. L. 104–193, title I, § 108(g)(8), title III, § 313(c), Aug. 22, 1996, 110 Stat. 2168, 2212; Pub. L. 104–208, div. C, title V, § 507(a), Sept. 30, 1996, 110 Stat. 3009–673; Pub. L. 106–169, title IV, § 401(p), Dec. 14, 1999, 113 Stat. 1859; Pub. L. 106–170, title IV, § 405(a), (b), Dec. 17, 1999, 113 Stat. 1911; Pub. L. 110–234, title IV, § 4002(b)(1)(A), (B), (2)(V), May 22, 2008, 122 Stat. 1095–1097; Pub. L. 110–246, § 4(a), title IV, § 4002(b)(1)(A), (B), (2)(V), June 18, 2008, 122 Stat. 1664, 1857, 1858; Pub. L. 113–79, title IV, § 4030(q), Feb. 7, 2014, 128 Stat. 815.)

CITE AS: 42 USC 1320b-7

§ 1320b–8. Hospital protocols for organ procurement and standards for organ procurement agencies
(a)
(1) The Secretary shall provide that a hospital or critical access hospital meeting the requirements of subchapter XVIII or XIX may participate in the program established under such subchapter only if—
(A) the hospital or critical access hospital establishes written protocols for the identification of potential organ donors that—
(i) assure that families of potential organ donors are made aware of the option of organ or tissue donation and their option to decline,
(ii) encourage discretion and sensitivity with respect to the circumstances, views, and beliefs of such families, and
(iii) require that such hospital’s designated organ procurement agency (as defined in paragraph (3)(B)) is notified of potential organ donors;
(B) in the case of a hospital in which organ transplants are performed, the hospital is a member of, and abides by the rules and requirements of, the Organ Procurement and Transplantation Network established pursuant to section 274 of this title (in this section referred to as the “Network”); and
(C) the hospital or critical access hospital has an agreement (as defined in paragraph (3)(A)) only with such hospital’s designated organ procurement agency.
(2)
(A) The Secretary shall grant a waiver of the requirements under subparagraphs (A)(iii) and (C) of paragraph (1) to a hospital or critical access hospital desiring to enter into an agreement with an organ procurement agency other than such hospital’s designated organ procurement agency if the Secretary determines that—
(i) the waiver is expected to increase organ donation; and
(ii) the waiver will assure equitable treatment of patients referred for transplants within the service area served by such hospital’s designated organ procurement agency and within the service area served by the organ procurement agency with which the hospital seeks to enter into an agreement under the waiver.
(B) In making a determination under subparagraph (A), the Secretary may consider factors that would include, but not be limited to—
(i) cost effectiveness;
(ii) improvements in quality;
(iii) whether there has been any change in a hospital’s designated organ procurement agency due to a change made on or after December 28, 1992, in the definitions for metropolitan statistical areas (as established by the Office of Management and Budget); and
(iv) the length and continuity of a hospital’s relationship with an organ procurement agency other than the hospital’s designated organ procurement agency;
except that nothing in this subparagraph shall be construed to permit the Secretary to grant a waiver that does not meet the requirements of subparagraph (A).
(C) Any hospital or critical access hospital seeking a waiver under subparagraph (A) shall submit an application to the Secretary containing such information as the Secretary determines appropriate.
(D) The Secretary shall—
(i) publish a public notice of any waiver application received from a hospital or critical access hospital under this paragraph within 30 days of receiving such application; and
(ii) prior to making a final determination on such application under subparagraph (A), offer interested parties the opportunity to submit written comments to the Secretary during the 60-day period beginning on the date such notice is published.
(3) For purposes of this subsection—
(A) the term “agreement” means an agreement described in section 273(b)(3)(A) of this title;
(B) the term “designated organ procurement agency” means, with respect to a hospital or critical access hospital, the organ procurement agency designated pursuant to subsection (b) for the service area in which such hospital is located; and
(C) the term “organ” means a human kidney, liver, heart, lung, pancreas, and any other human organ or tissue specified by the Secretary for purposes of this subsection.
(b)
(1) The Secretary shall provide that payment may be made under subchapter XVIII or XIX with respect to organ procurement costs attributable to payments made to an organ procurement agency only if the agency—
(A)
(i) is a qualified organ procurement organization (as described in section 273(b) of this title) that is operating under a grant made under section 273(a) of this title, or (ii) has been certified or recertified by the Secretary within the previous 2 years (4 years if the Secretary determines appropriate for an organization on the basis of its past practices) as meeting the standards to be a qualified organ procurement organization (as so described);
(B) meets the requirements that are applicable under such subchapter for organ procurement agencies;
(C) meets performance-related standards prescribed by the Secretary;
(D) is a member of, and abides by the rules and requirements of, the Network;
(E) allocates organs, within its service area and nationally, in accordance with medical criteria and the policies of the Network; and
(F) is designated by the Secretary as an organ procurement organization payments to which may be treated as organ procurement costs for purposes of reimbursement under such subchapter.
(2) The Secretary may not designate more than one organ procurement organization for each service area (described in section 273(b)(1)(E) 1
1 See References in Text note below.
of this title) under paragraph (1)(F).
(Aug. 14, 1935, ch. 531, title XI, § 1138, as added Pub. L. 99–509, title IX, § 9318(a), Oct. 21, 1986, 100 Stat. 2009; amended Pub. L. 100–203, title IV, § 4039(h)(2), Dec. 22, 1987, as added Pub. L. 100–360, title IV, § 411(e)(3), July 1, 1988, 102 Stat. 775; amended Pub. L. 101–239, title VI, § 6003(g)(3)(D)(iv), Dec. 19, 1989, 103 Stat. 2153; Pub. L. 103–432, title I, § 155(a)(1), Oct. 31, 1994, 108 Stat. 4438; Pub. L. 105–33, title IV, §§ 4201(c)(1), 4642, Aug. 5, 1997, 111 Stat. 373, 487.)

CITE AS: 42 USC 1320b-8

§ 1320b–9. Improved access to, and delivery of, health care for Indians under subchapters XIX and XXI
(a) Agreements with States for Medicaid and CHIP outreach on or near reservations to increase the enrollment of Indians in those programs
(1) In general
(2) Construction
(b) Requirement to facilitate cooperation
(c) Definition of Indian; Indian Tribe; Indian Health Program; Tribal Organization; Urban Indian Organization
(Aug. 14, 1935, ch. 531, title XI, § 1139, as added Pub. L. 100–203, title IX, § 9136, Dec. 22, 1987, 101 Stat. 1330–316; amended Pub. L. 100–647, title VIII, § 8201, Nov. 10, 1988, 102 Stat. 3798; Pub. L. 101–45, title IV, § 409, June 30, 1989, 103 Stat. 130; Pub. L. 101–239, title VI, § 6221, Dec. 19, 1989, 103 Stat. 2255; Pub. L. 101–508, title IV, § 4207(k)(6), formerly § 4027(k)(6), title V, § 5057, Nov. 5, 1990, 104 Stat. 1388–125, 1388–230; Pub. L. 103–432, title I, § 160(d)(4), title II, § 264(d), Oct. 31, 1994, 108 Stat. 4444, 4468; Pub. L. 111–3, title II, § 202(a), Feb. 4, 2009, 123 Stat. 39; Pub. L. 111–148, title II, § 2901(d), Mar. 23, 2010, 124 Stat. 333.)

CITE AS: 42 USC 1320b-9

§ 1320b–9a. Child health quality measures
(a) Development of an initial core set of health care quality measures for children enrolled in Medicaid or CHIP
(1) In general
(2) Identification of initial core measures
(3) Recommendations and disseminationBased on such existing and identified measures, the Secretary shall publish an initial core set of child health quality measures that includes (but is not limited to) the following:
(A) The duration of children’s health insurance coverage over a 12-month time period.
(B) The availability and effectiveness of a full range of—
(i) preventive services, treatments, and services for acute conditions, including services to promote healthy birth, prevent and treat premature birth, and detect the presence or risk of physical or mental conditions that could adversely affect growth and development; and
(ii) treatments to correct or ameliorate the effects of physical and mental conditions, including chronic conditions and, with respect to dental care, conditions requiring the restoration of teeth, relief of pain and infection, and maintenance of dental health, in infants, young children, school-age children, and adolescents.
(C) The availability of care in a range of ambulatory and inpatient health care settings in which such care is furnished.
(D) The types of measures that, taken together, can be used to estimate the overall national quality of health care for children, including children with special needs, and to perform comparative analyses of pediatric health care quality and racial, ethnic, and socioeconomic disparities in child health and health care for children.
(4) Encourage voluntary and standardized reporting and mandatory reporting
(A) Voluntary reporting
(B) Mandatory reporting
(5) Adoption of best practices in implementing quality programs
(6) Reports to CongressNot later than January 1, 2011, and every 3 years thereafter, the Secretary shall report to Congress on—
(A) the status of the Secretary’s efforts to improve—
(i) quality related to the duration and stability of health insurance coverage for children under subchapters XIX and XXI;
(ii) the quality of children’s health care under such subchapters, including preventive health services, dental care, health care for acute conditions, chronic health care, and health services to ameliorate the effects of physical and mental conditions and to aid in growth and development of infants, young children, school-age children, and adolescents with special health care needs; and
(iii) the quality of children’s health care under such subchapters across the domains of quality, including clinical quality, health care safety, family experience with health care, health care in the most integrated setting, and elimination of racial, ethnic, and socioeconomic disparities in health and health care;
(B) the status of voluntary reporting by States under subchapters XIX and XXI, utilizing the initial core quality measurement set and, beginning with the report required on January 1, 2025, and for each annual report thereafter, the status of mandatory reporting by States under subchapters XIX and XXI, utilizing the initial core quality measurement set and any updates or changes to that set; and
(C) any recommendations for legislative changes needed to improve the quality of care provided to children under subchapters XIX and XXI, including recommendations for quality reporting by States.
(7) Technical assistance
(8) Definition of core setIn this section, the term “core set” means a group of valid, reliable, and evidence-based quality measures that, taken together—
(A) provide information regarding the quality of health coverage and health care for children;
(B) address the needs of children throughout the developmental age span; and
(C) allow purchasers, families, and health care providers to understand the quality of care in relation to the preventive needs of children, treatments aimed at managing and resolving acute conditions, and diagnostic and treatment services whose purpose is to correct or ameliorate physical, mental, or developmental conditions that could, if untreated or poorly treated, become chronic.
(b) Advancing and improving pediatric quality measures
(1) Establishment of pediatric quality measures programNot later than January 1, 2011, the Secretary shall establish a pediatric quality measures program to—
(A) improve and strengthen the initial core child health care quality measures established by the Secretary under subsection (a);
(B) expand on existing pediatric quality measures used by public and private health care purchasers and advance the development of such new and emerging quality measures; and
(C) increase the portfolio of evidence-based, consensus pediatric quality measures available to public and private purchasers of children’s health care services, providers, and consumers.
(2) Evidence-based measuresThe measures developed under the pediatric quality measures program shall, at a minimum, be—
(A) evidence-based and, where appropriate, risk adjusted;
(B) designed to identify and eliminate racial and ethnic disparities in child health and the provision of health care;
(C) designed to ensure that the data required for such measures is collected and reported in a standard format that permits comparison of quality and data at a State, plan, and provider level;
(D) periodically updated; and
(E) responsive to the child health needs, services, and domains of health care quality described in clauses (i), (ii), and (iii) of subsection (a)(6)(A).
(3) Process for pediatric quality measures program
(A) States;
(B) pediatricians, children’s hospitals, and other primary and specialized pediatric health care professionals (including members of the allied health professions) who specialize in the care and treatment of children, particularly children with special physical, mental, and developmental health care needs;
(C) dental professionals, including pediatric dental professionals;
(D) health care providers that furnish primary health care to children and families who live in urban and rural medically underserved communities or who are members of distinct population sub-groups at heightened risk for poor health outcomes;
(E) national organizations representing children, including children with disabilities and children with chronic conditions;
(F) national organizations representing consumers and purchasers of children’s health care;
(G) national organizations and individuals with expertise in pediatric health quality measurement; and
(H) voluntary consensus standards setting organizations and other organizations involved in the advancement of evidence-based measures of health care.
(4) Developing, validating, and testing a portfolio of pediatric quality measuresAs part of the program to advance pediatric quality measures, the Secretary shall—
(A) award grants and contracts for the development, testing, and validation of new, emerging, and innovative evidence-based measures for children’s health care services across the domains of quality described in clauses (i), (ii), and (iii) of subsection (a)(6)(A); and
(B) award grants and contracts for—
(i) the development of consensus on evidence-based measures for children’s health care services;
(ii) the dissemination of such measures to public and private purchasers of health care for children; and
(iii) the updating of such measures as necessary.
(5) Revising, strengthening, and improving initial core measures
(6) Definition of pediatric quality measure
(7) Construction
(c) Annual State reports regarding State-specific quality of care measures applied under Medicaid or CHIP
(1) Annual State reportsEach State with a State plan approved under subchapter XIX or a State child health plan approved under subchapter XXI shall annually report to the Secretary on the—
(A) State-specific child health quality measures applied by the States under such plans, including measures described in subparagraphs (A) and (B) of subsection (a)(6) and, beginning with the annual report on fiscal year 2024, all of the core measures described in subsection (a) and any updates or changes to those measures; and
(B) State-specific information on the quality of health care furnished to children under such plans, including information collected through external quality reviews of managed care organizations under section 1396u–2 of this title and benchmark plans under sections 1396u–7 and 1397cc of this title.
(2) Publication
(d) Demonstration projects for improving the quality of children’s health care and the use of health information technology
(1) In generalDuring the period of fiscal years 2009 through 2013, the Secretary shall award not more than 10 grants to States and child health providers to conduct demonstration projects to evaluate promising ideas for improving the quality of children’s health care provided under subchapter XIX or XXI, including projects to—
(A) experiment with, and evaluate the use of, new measures of the quality of children’s health care under such subchapters (including testing the validity and suitability for reporting of such measures);
(B) promote the use of health information technology in care delivery for children under such subchapters;
(C) evaluate provider-based models which improve the delivery of children’s health care services under such subchapters, including care management for children with chronic conditions and the use of evidence-based approaches to improve the effectiveness, safety, and efficiency of health care services for children; or
(D) demonstrate the impact of the model electronic health record format for children developed and disseminated under subsection (f) on improving pediatric health, including the effects of chronic childhood health conditions, and pediatric health care quality as well as reducing health care costs.
(2) RequirementsIn awarding grants under this subsection, the Secretary shall ensure that—
(A) only 1 demonstration project funded under a grant awarded under this subsection shall be conducted in a State; and
(B) demonstration projects funded under grants awarded under this subsection shall be conducted evenly between States with large urban areas and States with large rural areas.
(3) Authority for multistate projects
(4) Funding
(e) Childhood obesity demonstration project
(1) Authority to conduct demonstrationThe Secretary, in consultation with the Administrator of the Centers for Medicare & Medicaid Services, shall conduct a demonstration project to develop a comprehensive and systematic model for reducing childhood obesity by awarding grants to eligible entities to carry out such project. Such model shall—
(A) identify, through self-assessment, behavioral risk factors for obesity among children;
(B) identify, through self-assessment, needed clinical preventive and screening benefits among those children identified as target individuals on the basis of such risk factors;
(C) provide ongoing support to such target individuals and their families to reduce risk factors and promote the appropriate use of preventive and screening benefits; and
(D) be designed to improve health outcomes, satisfaction, quality of life, and appropriate use of items and services for which medical assistance is available under subchapter XIX or child health assistance is available under subchapter XXI among such target individuals.
(2) Eligibility entities 2
2 So in original. Probably should be “Eligible entities”.
For purposes of this subsection, an eligible entity is any of the following:
(A) A city, county, or Indian tribe.
(B) A local or tribal educational agency.
(C) An accredited university, college, or community college.
(D) A Federally-qualified health center.
(E) A local health department.
(F) A health care provider.
(G) A community-based organization.
(H) Any other entity determined appropriate by the Secretary, including a consortia 3
3 So in original. Probably should be “consortium”.
or partnership of entities described in any of subparagraphs (A) through (G).
(3) Use of fundsAn eligible entity awarded a grant under this subsection shall use the funds made available under the grant to—
(A) carry out community-based activities related to reducing childhood obesity, including by—
(i) forming partnerships with entities, including schools and other facilities providing recreational services, to establish programs for after school and weekend community activities that are designed to reduce childhood obesity;
(ii) forming partnerships with daycare facilities to establish programs that promote healthy eating behaviors and physical activity; and
(iii) developing and evaluating community educational activities targeting good nutrition and promoting healthy eating behaviors;
(B) carry out age-appropriate school-based activities that are designed to reduce childhood obesity, including by—
(i) developing and testing educational curricula and intervention programs designed to promote healthy eating behaviors and habits in youth, which may include—(I) after hours physical activity programs; and(II) science-based interventions with multiple components to prevent eating disorders including nutritional span, understanding and responding to hunger and satiety, positive body image development, positive self-esteem development, and learning life skills (such as stress management, communication skills, problemsolving and decisionmaking skills), as well as consideration of cultural and developmental issues, and the role of family, school, and community;
(ii) providing education and training to educational professionals regarding how to promote a healthy lifestyle and a healthy school environment for children;
(iii) planning and implementing a healthy lifestyle curriculum or program with an emphasis on healthy eating behaviors and physical activity; and
(iv) planning and implementing healthy lifestyle classes or programs for parents or guardians, with an emphasis on healthy eating behaviors and physical activity for children;
(C) carry out educational, counseling, promotional, and training activities through the local health care delivery systems including by—
(i) promoting healthy eating behaviors and physical activity services to treat or prevent eating disorders, being overweight, and obesity;
(ii) providing patient education and counseling to increase physical activity and promote healthy eating behaviors;
(iii) training health professionals on how to identify and treat obese and overweight individuals which may include nutrition and physical activity counseling; and
(iv) providing community education by a health professional on good nutrition and physical activity to develop a better understanding of the relationship between diet, physical activity, and eating disorders, obesity, or being overweight; and
(D) provide, through qualified health professionals, training and supervision for community health workers to—
(i) educate families regarding the relationship between nutrition, eating habits, physical activity, and obesity;
(ii) educate families about effective strategies to improve nutrition, establish healthy eating patterns, and establish appropriate levels of physical activity; and
(iii) educate and guide parents regarding the ability to model and communicate positive health behaviors.
(4) PriorityIn awarding grants under paragraph (1), the Secretary shall give priority to awarding grants to eligible entities—
(A) that demonstrate that they have previously applied successfully for funds to carry out activities that seek to promote individual and community health and to prevent the incidence of chronic disease and that can cite published and peer-reviewed research demonstrating that the activities that the entities propose to carry out with funds made available under the grant are effective;
(B) that will carry out programs or activities that seek to accomplish a goal or goals set by the State in the Healthy People 2010 plan of the State;
(C) that provide non-Federal contributions, either in cash or in-kind, to the costs of funding activities under the grants;
(D) that develop comprehensive plans that include a strategy for extending program activities developed under grants in the years following the fiscal years for which they receive grants under this subsection;
(E) located in communities that are medically underserved, as determined by the Secretary;
(F) located in areas in which the average poverty rate is at least 150 percent or higher of the average poverty rate in the State involved, as determined by the Secretary; and
(G) that submit plans that exhibit multisectoral, cooperative conduct that includes the involvement of a broad range of stakeholders, including—
(i) community-based organizations;
(ii) local governments;
(iii) local educational agencies;
(iv) the private sector;
(v) State or local departments of health;
(vi) accredited colleges, universities, and community colleges;
(vii) health care providers;
(viii) State and local departments of transportation and city planning; and
(ix) other entities determined appropriate by the Secretary.
(5) Program design
(A) Initial design
(B) Number and project areas
(6) Report to Congress
(7) DefinitionsIn this subsection:
(A) Federally-qualified health center
(B) Indian tribe
(C) Self-assessmentThe term “self-assessment” means a form that—
(i) includes questions regarding—(I) behavioral risk factors;(II) needed preventive and screening services; and(III) target individuals’ preferences for receiving follow-up information;
(ii) is assessed using such computer generated assessment programs; and
(iii) allows for the provision of such ongoing support to the individual as the Secretary determines appropriate.
(D) Ongoing supportThe term “ongoing support” means—
(i) to provide any target individual with information, feedback, health coaching, and recommendations regarding—(I) the results of a self-assessment given to the individual;(II) behavior modification based on the self-assessment; and(III) any need for clinical preventive and screening services or treatment including medical nutrition therapy;
(ii) to provide any target individual with referrals to community resources and programs available to assist the target individual in reducing health risks; and
(iii) to provide the information described in clause (i) to a health care provider, if designated by the target individual to receive such information.
(8) Appropriation
(f) Development of model electronic health record format for children enrolled in Medicaid or CHIP
(1) In generalNot later than January 1, 2010, the Secretary shall establish a program to encourage the development and dissemination of a model electronic health record format for children enrolled in the State plan under subchapter XIX or the State child health plan under subchapter XXI that is—
(A) subject to State laws, accessible to parents, caregivers, and other consumers for the sole purpose of demonstrating compliance with school or leisure activity requirements, such as appropriate immunizations or physicals;
(B) designed to allow interoperable exchanges that conform with Federal and State privacy and security requirements;
(C) structured in a manner that permits parents and caregivers to view and understand the extent to which the care their children receive is clinically appropriate and of high quality; and
(D) capable of being incorporated into, and otherwise compatible with, other standards developed for electronic health records.
(2) Funding
(g) Study of pediatric health and health care quality measures
(1) In generalNot later than July 1, 2010, the Institute of Medicine shall study and report to Congress on the extent and quality of efforts to measure child health status and the quality of health care for children across the age span and in relation to preventive care, treatments for acute conditions, and treatments aimed at ameliorating or correcting physical, mental, and developmental conditions in children. In conducting such study and preparing such report, the Institute of Medicine shall—
(A) consider all of the major national population-based reporting systems sponsored by the Federal Government that are currently in place, including reporting requirements under Federal grant programs and national population surveys and estimates conducted directly by the Federal Government;
(B) identify the information regarding child health and health care quality that each system is designed to capture and generate, the study and reporting periods covered by each system, and the extent to which the information so generated is made widely available through publication;
(C) identify gaps in knowledge related to children’s health status, health disparities among subgroups of children, the effects of social conditions on children’s health status and use and effectiveness of health care, and the relationship between child health status and family income, family stability and preservation, and children’s school readiness and educational achievement and attainment; and
(D) make recommendations regarding improving and strengthening the timeliness, quality, and public transparency and accessibility of information about child health and health care quality.
(2) Funding
(h) Rule of construction
(i) Appropriation
(1) In generalOut of any funds in the Treasury not otherwise appropriated, there is appropriated—
(A) for each of fiscal years 2009 through 2013, $45,000,000 for the purpose of carrying out this section (other than subsection (e));
(B) for the period of fiscal years 2016 and 2017, $20,000,000 for the purpose of carrying out this section (other than subsections (e), (f), and (g));
(C) for the period of fiscal years 2018 through 2023, $90,000,000 for the purpose of carrying out this section (other than subsections (e), (f), and (g));
(D) for the period of fiscal years 2024 through 2027, $60,000,000 for the purpose of carrying out this section (other than subsections (e), (f), and (g)); and
(E) for each of fiscal years 2028 and 2029, $15,000,000 for the purpose of carrying out this section (other than subsections (e), (f), and (g)).
(2) Availability
(Aug. 14, 1935, ch. 531, title XI, § 1139A, as added and amended Pub. L. 111–3, title IV, § 401(a), title V, § 501(g), Feb. 4, 2009, 123 Stat. 72, 88; Pub. L. 111–148, title IV, § 4306, Mar. 23, 2010, 124 Stat. 587; Pub. L. 114–10, title III, § 304, Apr. 16, 2015, 129 Stat. 158; Pub. L. 115–120, div. C, § 3003, Jan. 22, 2018, 132 Stat. 36; Pub. L. 115–123, div. E, title I, § 50102, Feb. 9, 2018, 132 Stat. 175; Pub. L. 117–328, div. FF, title V, § 5111(c)(1), Dec. 29, 2022, 136 Stat. 5939.)

CITE AS: 42 USC 1320b-9a

§ 1320b–9b. Adult health quality measures
(a) Development of core set of health care quality measures for adults eligible for benefits under Medicaid
(b) Deadlines
(1) Recommended measures
(2) Dissemination
(3) Standardized reporting
(A) Voluntary reporting
(B) Mandatory reporting with respect to behavioral health measures
(4) Reports to Congress
(5) Establishment of Medicaid quality measurement program
(A) In general
(B) Revising, strengthening, and improving initial core measures
(C) Behavioral health measures
(c) Construction
(d) Annual State reports regarding State-specific quality of care measures applied under Medicaid
(1) Annual State reports
Each State with a State plan or waiver approved under subchapter XIX shall annually report (separately or as part of the annual report required under section 1320b–9a(c) of this title), to the Secretary on the—
(A) State-specific adult health quality measures applied by the State under such plan, including measures described in subsection (b)(5) and, beginning with the report for 2024, all behavioral health measures included in the core set of adult health quality measures maintained under such subsection (b)(5) and any updates or changes to such measures (as required under subsection (b)(3)); and
(B) State-specific information on the quality of health care furnished to Medicaid eligible adults under such plan, including information collected through external quality reviews of managed care organizations under
(2) Publication
(e) Appropriation
(Aug. 14, 1935, ch. 531, title XI, § 1139B, as added Pub. L. 111–148, title II, § 2701, Mar. 23, 2010, 124 Stat. 317; amended Pub. L. 113–93, title II, § 210, Apr. 1, 2014, 128 Stat. 1047; Pub. L. 115–271, title V, § 5001, Oct. 24, 2018, 132 Stat. 3961.)

CITE AS: 42 USC 1320b-9b

§ 1320b–10. Prohibitions relating to references to Social Security or Medicare
(a) Prohibited acts
(1) No person may use, in connection with any item constituting an advertisement, solicitation, circular, book, pamphlet, or other communication (including any Internet or other electronic communication), or a play, motion picture, broadcast, telecast, or other production, alone or with other words, letters, symbols, or emblems—
(A) the words “Social Security”, “Social Security Account”, “Social Security System”, “Social Security Administration”, “Medicare”, “Centers for Medicare & Medicaid Services”, “Department of Health and Human Services”, “Health and Human Services”, “Supplemental Security Income Program”, “Medicaid”, “Death Benefits Update”, “Federal Benefit Information”, “Funeral Expenses”, or “Final Supplemental Plan”, the letters “SSA”, “CMS”, “DHHS”, “HHS”, or “SSI”, or any other combination or variation of such words or letters, or
(B) a symbol or emblem of the Social Security Administration, Centers for Medicare & Medicaid Services, or Department of Health and Human Services (including the design of, or a reasonable facsimile of the design of, the social security card issued pursuant to section 405(c)(2)(F) of this title or the Medicare card,,1
1 So in original.
the check used for payment of benefits under subchapter II, or envelopes or other stationery used by the Social Security Administration, Centers for Medicare & Medicaid Services, or Department of Health and Human Services), or any other combination or variation of such symbols or emblems,
in a manner which such person knows or should know would convey, or in a manner which reasonably could be interpreted or construed as conveying, the false impression that such item is approved, endorsed, or authorized by the Social Security Administration, the Centers for Medicare & Medicaid Services, or the Department of Health and Human Services or that such person has some connection with, or authorization from, the Social Security Administration, the Centers for Medicare & Medicaid Services, or the Department of Health and Human Services. The preceding provisions of this subsection shall not apply with respect to the use by any agency or instrumentality of a State or political subdivision of a State of any words or letters which identify an agency or instrumentality of such State or of a political subdivision of such State or the use by any such agency or instrumentality of any symbol or emblem of an agency or instrumentality of such State or a political subdivision of such State.
(2)
(A) No person may, for a fee, reproduce, reprint, or distribute any item consisting of a form, application, or other publication of the Social Security Administration unless such person has obtained specific, written authorization for such activity in accordance with regulations which the Commissioner of Social Security shall prescribe.
(B) No person may, for a fee, reproduce, reprint, or distribute any item consisting of a form, application, or other publication of the Department of Health and Human Services unless such person has obtained specific, written authorization for such activity in accordance with regulations which the Secretary shall prescribe.
(3) Any determination of whether the use of one or more words, letters, symbols, or emblems (or any combination or variation thereof) in connection with an item described in paragraph (1) or the reproduction, reprinting, or distribution of an item described in paragraph (2) is a violation of this subsection shall be made without regard to any inclusion in such item (or any so reproduced, reprinted, or distributed copy thereof) of a disclaimer of affiliation with the United States Government or any particular agency or instrumentality thereof.
(4)
(A) No person shall offer, for a fee, to assist an individual to obtain a product or service that the person knows or should know is provided free of charge by the Social Security Administration unless, at the time the offer is made, the person provides to the individual to whom the offer is tendered a notice that—
(i) explains that the product or service is available free of charge from the Social Security Administration, and
(ii) complies with standards prescribed by the Commissioner of Social Security respecting the span of such notice and its placement, visibility, and legibility.
(B) Subparagraph (A) shall not apply to any offer—
(i) to serve as a claimant representative in connection with a claim arising under subchapter II, subchapter VIII, or subchapter XVI; or
(ii) to prepare, or assist in the preparation of, an individual’s plan for achieving self-support under subchapter XVI.
(b) Civil penaltiesThe Commissioner or the Secretary (as applicable) may, pursuant to regulations, impose a civil money penalty not to exceed—
(1) except as provided in paragraph (2), $5,000, or
(2) in the case of a violation consisting of a broadcast or telecast, $25,000,
against any person for each violation by such person of subsection (a). In the case of any items referred to in subsection (a)(1) consisting of pieces of mail, each such piece of mail which contains one or more words, letters, symbols, or emblems in violation of subsection (a) shall represent a separate violation. In the case of any items referred to in subsection (a)(1) consisting of Internet or other electronic communications, each dissemination, viewing, or accessing of such a communication which contains one or more words, letters, symbols, or emblems in violation of subsection (a) shall represent a separate violation 2
2 So in original. Probably should be followed by a period.
In the case of any item referred to in subsection (a)(2), the reproduction, reprinting, or distribution of such item shall be treated as a separate violation with respect to each copy thereof so reproduced, reprinted, or distributed.
(c) Application of other law; compromise, recovery, and deposit into Treasury of civil money penalties
(1) The provisions of section 1320a–7a of this title (other than subsections (a), (b), (f), (h), and (i) and the first sentence of subsection (c)) shall apply to civil money penalties under subsection (b) in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.
(2) Penalties imposed against a person under subsection (b) may be compromised by the Commissioner or the Secretary (as applicable) and may be recovered in a civil action in the name of the United States brought in the district court of the United States for the district in which the violation occurred or where the person resides, has its principal office, or may be found, as determined by the Commissioner or the Secretary (as applicable). Amounts recovered under this section shall be paid to the Commissioner or the Secretary (as applicable) and shall be deposited as miscellaneous receipts of the Treasury of the United States, except that (A) to the extent that such amounts are recovered under this section as penalties imposed for misuse of words, letters, symbols, or emblems relating to the Social Security Administration, such amounts shall be deposited into the Federal Old-Age and Survivors Insurance Trust Fund, and (B) to the extent that such amounts are recovered under this section as penalties imposed for misuse of words, letters, symbols, or emblems relating to the Department of Health and Human Services, such amounts shall be deposited into the Federal Hospital Insurance Trust Fund or the Federal Supplementary Medical Insurance Trust Fund, as appropriate. The amount of such penalty when finally determined, or the amount agreed upon in compromise, may be deducted from any sum then or later owing by the United States to the person against whom the penalty has been imposed.
(d) Enforcement
(Aug. 14, 1935, ch. 531, title XI, § 1140, as added Pub. L. 100–360, title IV, § 428(a), July 1, 1988, 102 Stat. 815; amended Pub. L. 100–485, title VI, § 608(d)(30)(A), Oct. 13, 1988, 102 Stat. 2424; Pub. L. 103–296, title I, § 108(b)(12), title III, §§ 304(b), 312(a)–(j), Aug. 15, 1994, 108 Stat. 1484, 1520, 1526, 1527; Pub. L. 108–173, title IX, § 900(e)(1)(B), Dec. 8, 2003, 117 Stat. 2371; Pub. L. 108–203, title II, §§ 204(a), 207(a), Mar. 2, 2004, 118 Stat. 511, 512; Pub. L. 114–74, title VIII, § 814, Nov. 2, 2015, 129 Stat. 604.)

CITE AS: 42 USC 1320b-10

§ 1320b–11. Blood donor locator service
(a) In general
(b) Provision of address informationWhenever the Commissioner of Social Security receives a request, filed by an authorized person (as defined in subsection (h)(1)), for the mailing address of a donor described in subsection (a) and the Commissioner of Social Security is reasonably satisfied that the requirements of this section have been met with respect to such request, the Commissioner of Social Security shall promptly undertake to provide the requested address information from—
(1) the files and records maintained by the Social Security Administration, and
(2) such files and records obtained pursuant to section 6103(m)(6) of the Internal Revenue Code of 1986 as the Commissioner of Social Security considers necessary to comply with such request.
(c) Manner and form of requests
(d) Procedures and safeguardsAny authorized person shall, as a condition for receiving address information from the Blood Donor Locator Service—
(1) establish and maintain, to the satisfaction of the Commissioner of Social Security, a system for standardizing records with respect to any request, the reason for such request, and the date of such request made by or of it and any disclosure of address information made by or to it,
(2) establish and maintain, to the satisfaction of the Commissioner of Social Security, a secure area or place in which such address information and all related blood donor records shall be stored,
(3) restrict, to the satisfaction of the Commissioner of Social Security, access to the address information and related blood donor records only to persons whose duties or responsibilities require access and to whom disclosure may be made under the provisions of this section,
(4) provide such other safeguards which the Commissioner of Social Security determines (and which the Commissioner of Social Security prescribes in regulations) to be necessary or appropriate to protect the confidentiality of the address information and related blood donor records,
(5) furnish a report to the Commissioner of Social Security, at such time and containing such information as the Commissioner of Social Security may prescribe, which describes the procedures established and utilized by the authorized person for ensuring the confidentiality of address information and related blood donor records required under this subsection, and
(6) destroy such address information and related blood donor records, upon completion of their use in providing the notification for which the information was obtained, so as to make such information and records undisclosable.
If the Commissioner of Social Security determines that any authorized person has failed to, or does not, meet the requirements of this subsection, the Commissioner of Social Security may, after any proceedings for review established under subsection (f), take such actions as are necessary to ensure such requirements are met, including refusing to disclose address information to such authorized person until the Commissioner of Social Security determines that such requirements have been or will be met. In the case of any authorized person who discloses any address information received pursuant to this section or any related blood donor records to any agent, this subsection shall apply to such authorized person and each such agent (except that, in the case of an agent, any report to the Commissioner of Social Security or other action with respect to the Commissioner of Social Security shall be made or taken through such authorized person). The Commissioner of Social Security shall destroy all related blood donor records in the possession of the Social Security Administration upon completion of their use in transmitting mailing addresses as required under subsection (a), so as to make such records undisclosable.
(e) Arrangements with State agencies and authorized personsThe Commissioner of Social Security, in carrying out the Commissioner’s duties and functions under this section, shall enter into arrangements—
(1) with State agencies to accept and to transmit to the Commissioner of Social Security requests for address information under this section and to accept and to transmit such information to authorized persons, and
(2) with State agencies and authorized persons otherwise to cooperate with the Commissioner of Social Security in carrying out the purposes of this section.
(f) Procedures for administrative review
(g) Unauthorized disclosure of information
(h) DefinitionsFor purposes of this section—
(1) Authorized personThe term “authorized person” means—
(A) any agency of a State (or of a political subdivision of a State) which has duties or authority under State law relating to the public health or otherwise has the duty or authority under State law to regulate blood donations, and
(B) any entity engaged in the acceptance of blood donations which is licensed or registered by the Food and Drug Administration in connection with the acceptance of such blood donations, and which, in accordance with such regulations as may be prescribed by the Commissioner of Social Security, provides for—
(i) the confidentiality of any address information received pursuant to this section and related blood donor records,
(ii) blood donor notification procedures for individuals with respect to whom such information is requested and a finding has been made that they have or may have the virus for acquired immune deficiency syndrome, and
(iii) counseling services for such individuals who have been found to have such virus.
(2) Related blood donor record
(3) State
(Aug. 14, 1935, ch. 531, title XI, § 1141, as added Pub. L. 100–647, title VIII, § 8008(b)(1), Nov. 10, 1988, 102 Stat. 3784; amended Pub. L. 103–296, title I, § 108(b)(13), Aug. 15, 1994, 108 Stat. 1484.)

CITE AS: 42 USC 1320b-11

§ 1320b–12. Research on outcomes of health care services and procedures
(a) Establishment of program
(1) In generalThe Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall—
(A) conduct and support research with respect to the outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically; and
(B) assure that the needs and priorities of the program under subchapter XVIII are appropriately reflected in the development and periodic review and updating (through the process set forth in section 299b–2 1
1 See References in Text note below.
of this title) of treatment-specific or condition-specific practice guidelines for clinical treatments and conditions in forms appropriate for use in clinical practice, for use in educational programs, and for use in reviewing quality and appropriateness of medical care.
(2) Evaluations of alternative services and procedures
(3) Initial guidelines
(A) In carrying out paragraph (1)(B) of this subsection, and section 299b–1(d) 1 of this title, the Secretary shall, by not later than January 1, 1991, assure the development of an initial set of the guidelines specified in paragraph (1)(B) that shall include not less than 3 clinical treatments or conditions that—
(i)(I) account for a significant portion of expenditures under subchapter XVIII; and(II) have a significant variation in the frequency or the type of treatment provided; or
(ii) otherwise meet the needs and priorities of the program under subchapter XVIII, as set forth under subsection (b)(3).
(B)
(i) The Secretary shall provide for the use of guidelines developed under subparagrah 2
2 So in original. Probably should be “subparagraph”.
(A) to improve the quality, effectiveness, and appropriateness of care provided under subchapter XVIII. The Secretary shall determine the impact of such use on the quality, appropriateness, effectiveness, and cost of medical care provided under such subchapter and shall report to the Congress on such determination by not later than January 1, 1993.
(ii) For the purpose of carrying out clause (i), the Secretary shall expend, from the amounts specified in clause (iii), $1,000,000 for fiscal year 1990 and $1,500,000 for each of the fiscal years 1991 and 1992.
(iii) For each fiscal year, for purposes of expenditures required in clause (ii)—(I) 60 percent of an amount equal to the expenditure involved is appropriated from the Federal Hospital Insurance Trust Fund (established under section 1395i of this title); and(II) 40 percent of an amount equal to the expenditure involved is appropriated from the Federal Supplementary Medical Insurance Trust Fund (established under section 1395t of this title).
(b) Priorities
(1) In generalThe Secretary shall establish priorities with respect to the diseases, disorders, and other health conditions for which research and evaluations are to be conducted or supported under subsection (a). In establishing such priorities, the Secretary shall, with respect to a disease, disorder, or other health condition, consider the extent to which—
(A) improved methods of prevention, diagnosis, treatment, and clinical management can benefit a significant number of individuals;
(B) there is significant variation among physicians in the particular services and procedures utilized in making diagnoses and providing treatments or there is significant variation in the outcomes of health care services or procedures due to different patterns of diagnosis or treatment;
(C) the services and procedures utilized for diagnosis and treatment result in relatively substantial expenditures; and
(D) the data necessary for such evaluations are readily available or can readily be developed.
(2) Preliminary assessments
(A) rates of utilization vary among similar populations for particular diseases, disorders, and other health conditions;
(B) uncertainties exist on the effect of utilizing a particular service or procedure; or
(C) inappropriate services and procedures are provided.
(3) Relationship with medicare program
(c) Methodologies and criteria for evaluationsFor the purpose of facilitating research under subsection (a), the Secretary shall—
(1) conduct and support research with respect to the improvement of methodologies and criteria utilized in conducting research with respect to outcomes of health care services and procedures;
(2) conduct and support reviews and evaluations of existing research findings with respect to such treatment or conditions;
(3) conduct and support reviews and evaluations of the existing methodologies that use large data bases in conducting such research and shall develop new research methodologies, including data-based methods of advancing knowledge and methodologies that measure clinical and functional status of patients, with respect to such research;
(4) provide grants and contracts to research centers, and contracts to other entities, to conduct such research on such treatment or conditions, including research on the appropriate use of prescription drugs;
(5) conduct and support research and demonstrations on the use of claims data and data on clinical and functional status of patients in determining the outcomes, effectiveness, and appropriateness of such treatment; and
(6) conduct and support supplementation of existing data bases, including the collection of new information, to enhance data bases for research purposes, and the design and development of new data bases that would be used in outcomes and effectiveness research.
(d) Standards for data basesIn carrying out this section, the Secretary shall develop—
(1) uniform definitions of data to be collected and used in describing a patient’s clinical and functional status;
(2) common reporting formats and linkages for such data; and
(3) standards to assure the security, confidentiality, accuracy, and appropriate maintenance of such data.
(e) Dissemination of research findings and guidelines
(1) In general
(2) Cooperative educational activities
(f) Evaluations
(g) Research with respect to dissemination
(h) Omitted
(i) Authorization of appropriations
(1) In generalThere are authorized to be appropriated to carry out this section—
(A) $50,000,000 for fiscal year 1990;
(B) $75,000,000 for fiscal year 1991;
(C) $110,000,000 for fiscal year 1992;
(D) $148,000,000 for fiscal year 1993; and
(E) $185,000,000 for fiscal year 1994.
(2) SpecificationsFor the purpose of carrying out this section, for each of the fiscal years 1990 through 1992 an amount equal to two-thirds of the amounts authorized to be appropriated under paragraph (1), and for each of the fiscal years 1993 and 1994 an amount equal to 70 percent of such amounts, are to be appropriated in the following proportions from the following trust funds:
(A) 60 percent from the Federal Hospital Insurance Trust Fund (established under section 1395i of this title).
(B) 40 percent from the Federal Supplementary Medical Insurance Trust Fund (established under section 1395t of this title).
(3) Allocations
(A) For each fiscal year, of the amounts transferred or otherwise appropriated to carry out this section, the Secretary shall reserve appropriate amounts for each of the purposes specified in clauses (i) through (iv) of subparagraph (B).
(B) The purposes referred to in subparagraph (A) are—
(i) the development of guidelines, standards, performance measures, and review criteria;
(ii) research and evaluation;
(iii) data-base standards and development; and
(iv) education and information dissemination.
(Aug. 14, 1935, ch. 531, title XI, § 1142, as added Pub. L. 101–239, title VI, § 6103(b)(1), Dec. 19, 1989, 103 Stat. 2195; amended Pub. L. 106–129, § 2(b)(2), Dec. 6, 1999, 113 Stat. 1670; Pub. L. 108–173, title IX, § 900(e)(1)(C), Dec. 8, 2003, 117 Stat. 2371.)

CITE AS: 42 USC 1320b-12

§ 1320b–13. Social security account statements
(a) Provision upon request
(1) Beginning not later than October 1, 1990, the Commissioner of Social Security shall provide upon the request of an eligible individual a social security account statement (hereinafter referred to as the “statement”).
(2) Each statement shall contain—
(A) the amount of wages paid to and self-employment income derived by the eligible individual as shown by the records of the Commissioner at the date of the request;
(B) an estimate of the aggregate of the employer, employee, and self-employment contributions of the eligible individual for old-age, survivors, and disability insurance as shown by the records of the Commissioner on the date of the request;
(C) a separate estimate of the aggregate of the employer, employee, and self-employment contributions of the eligible individual for hospital insurance as shown by the records of the Commissioner on the date of the request;
(D) an estimate of the potential monthly retirement, disability, survivor, and auxiliary benefits payable on the eligible individual’s account together with a description of the benefits payable under the medicare program of subchapter XVIII; and
(E) in the case of an eligible individual described in paragraph (3)(C)(ii), an explanation, in language calculated to be understood by the average eligible individual, of the operation of the provisions under sections 402(k)(5) and 415(a)(7) of this title and an explanation of the maximum potential effects of such provisions on the eligible individual’s monthly retirement, survivor, and auxiliary benefits.
(3) For purposes of this section, the term “eligible individual” means an individual—
(A) who has a social security account number,
(B) who has attained age 25 or over, and
(C)
(i) who has wages or net earnings from self-employment, or (ii) with respect to whom the Commissioner has information that the pattern of wages or self-employment income indicate a likelihood of noncovered employment.
(b) Notice to eligible individuals
(c) Mandatory provision of statements
(1) By not later than September 30, 1995, the Commissioner shall provide a statement to each eligible individual who has attained age 60 by October 1, 1994, and who is not receiving benefits under subchapter II and for whom a current mailing address can be determined through such methods as the Commissioner determines to be appropriate. In fiscal years 1995 through 1999 the Commissioner shall provide a statement to each eligible individual who attains age 60 in such fiscal years and who is not receiving benefits under subchapter II and for whom a current mailing address can be determined through such methods as the Commissioner determines to be appropriate. The Commissioner shall provide with each statement to an eligible individual notice that such statement is updated annually and is available upon request.
(2) Beginning not later than October 1, 1999, the Commissioner shall provide a statement on an annual basis to each eligible individual who is not receiving benefits under subchapter II and for whom a mailing address can be determined through such methods as the Commissioner determines to be appropriate. With respect to statements provided to eligible individuals who have not attained age 50, such statements need not include estimates of monthly retirement benefits. However, if such statements provided to eligible individuals who have not attained age 50 do not include estimates of retirement benefit amounts, such statements shall include a description of the benefits (including auxiliary benefits) that are available upon retirement.
(d) Disclosure to governmental employees of effect of noncovered employment
(1) In the case of any individual commencing employment on or after January 1, 2005, in any agency or instrumentality of any State (or political subdivision thereof, as defined in section 418(b)(2) of this title) in a position in which service performed by the individual does not constitute “employment” as defined in section 410 of this title, the head of the agency or instrumentality shall ensure that, prior to the date of the commencement of the individual’s employment in the position, the individual is provided a written notice setting forth an explanation, in language calculated to be understood by the average individual, of the maximum effect on computations of primary insurance amounts (under section 415(a)(7) of this title) and the effect on benefit amounts (under section 402(k)(5) of this title) of monthly periodic payments or benefits payable based on earnings derived in such service. Such notice shall be in a form which shall be prescribed by the Commissioner of Social Security.
(2) The written notice provided to an individual pursuant to paragraph (1) shall include a form which, upon completion and signature by the individual, would constitute certification by the individual of receipt of the notice. The agency or instrumentality providing the notice to the individual shall require that the form be completed and signed by the individual and submitted to the agency or instrumentality and to the pension, annuity, retirement, or similar fund or system established by the governmental entity involved responsible for paying the monthly periodic payments or benefits, before commencement of service with the agency or instrumentality.
(Aug. 14, 1935, ch. 531, title XI, § 1143, formerly § 1142, as added Pub. L. 101–239, title X, § 10308, Dec. 19, 1989, 103 Stat. 2485; renumbered § 1143 and amended Pub. L. 101–508, title V, § 5111(a), Nov. 5, 1990, 104 Stat. 1388–272; Pub. L. 105–78, title VI, § 605, Nov. 13, 1997, 111 Stat. 1521; Pub. L. 108–203, title IV, §§ 419(a)–(c), 421, Mar. 2, 2004, 118 Stat. 533–535.)

CITE AS: 42 USC 1320b-13

§ 1320b–14. Outreach efforts to increase awareness of the availability of medicare cost-sharing and subsidies for low-income individuals under subchapter XVIII
(a) Outreach
(1) In general
The Commissioner of Social Security (in this section referred to as the “Commissioner”) shall conduct outreach efforts to—
(A) identify individuals entitled to benefits under the medicare program under subchapter XVIII who may be eligible for medical assistance for payment of the cost of medicare cost-sharing under the medicaid program pursuant to sections 1396a(a)(10)(E) and 1396u–3 of this title 1
1 So in original. Probably should be followed by a comma.
for the transitional assistance under section 1395w–141(f) of this title, or for premium and cost-sharing subsidies under section 1395w–114 of this title; and
(B) notify such individuals of the availability of such medical assistance, program, and subsidies under such sections.
(2) Content of notice
Any notice furnished under paragraph (1) shall state that eligibility for medicare cost-sharing assistance, the transitional assistance under section 1395w–141(f) of this title, or premium and cost-sharing subsidies under section 1395w–114 of this title under such sections is conditioned upon—
(A) the individual providing to the State information about income and resources (in the case of an individual residing in a State that imposes an assets test for eligibility for medicare cost-sharing under the medicaid program); and
(B) meeting the applicable eligibility criteria.
(b) Coordination with States
(1) In general
In conducting the outreach efforts under this section, the Commissioner shall—
(A) furnish the agency of each State responsible for the administration of the medicaid program and any other appropriate State agency with information consisting of the name and address of individuals residing in the State that the Commissioner determines may be eligible for medical assistance for payment of the cost of medicare cost-sharing under the medicaid program pursuant to sections 1396a(a)(10)(E) and 1396u–3 of this title, for transitional assistance under section 1395w–141(f) of this title, or for premium and cost-sharing subsidies for low-income individuals under section 1395w–114 of this title; and
(B) update any such information not less frequently than once per year.
(2) Information in periodic updates
(c) Assistance with Medicare Savings Program and low-income subsidy program applications
(1) Distribution of applications and information to individuals who are potentially eligible for low-income subsidy program
For each individual who submits an application for low-income subsidies under section 1395w–114 of this title, requests an application for such subsidies, or is otherwise identified as an individual who is potentially eligible for such subsidies, the Commissioner shall do the following:
(A) Provide information describing the low-income subsidy program under section 1395w–114 of this title and the Medicare Savings Program (as defined in paragraph (7)).
(B) Provide an application for enrollment under such low-income subsidy program (if not already received by the Commissioner).
(C) In accordance with paragraph (3), transmit data from such an application for purposes of initiating an application for benefits under the Medicare Savings Program.
(D) Provide information on how the individual may obtain assistance in completing such application and an application under the Medicare Savings Program, including information on how the individual may contact the State health insurance assistance program (SHIP).
(E) Make the application described in subparagraph (B) and the information described in subparagraphs (A) and (D) available at local offices of the Social Security Administration.
(2) Training personnel in explaining benefit programs and assisting in completing LIS application
(3) Transmittal of data to States
(4) Coordination with outreach
(5) Reimbursement of Social Security Administration administrative costs
(A) Initial Medicare Savings Program costs; additional low-income subsidy costs
(i) Initial Medicare Savings Program costs
(ii) Additional amount for low-income subsidy activities
(B) Subsequent funding under agreements
(i) In general
Effective for fiscal years beginning on or after October 1, 2010, the Commissioner and the Secretary shall enter into an agreement which shall provide funding (subject to the amount appropriated under clause (ii)) to cover the administrative costs of the Commissioner’s activities under this subsection. Such agreement shall—
(I) provide funds to the Commissioner for the full cost of the Social Security Administration’s work related to the Medicare Savings Program required under this section;(II) provide such funding quarterly in advance of the applicable quarter based on estimating methodology agreed to by the Commissioner and the Secretary; and(III) require an annual accounting and reconciliation of the actual costs incurred and funds provided under this subsection.
(ii) Appropriation
(C) Limitation
(6) GAO analysis and report
(A) Analysis
The Comptroller General of the United States shall prepare an analysis of the impact of this subsection—
(i) in increasing participation in the Medicare Savings Program, and
(ii) on States and the Social Security Administration.
(B) Report
(7) Medicare Savings Program defined
(Aug. 14, 1935, ch. 531, title XI, § 1144, as added Pub. L. 106–554, § 1(a)(6) [title IX, § 911(a)(1)], Dec. 21, 2000, 114 Stat. 2763, 2763A–583; amended Pub. L. 108–173, title I, § 103(g), Dec. 8, 2003, 117 Stat. 2160; Pub. L. 110–275, title I, § 113(a), July 15, 2008, 122 Stat. 2503.)

CITE AS: 42 USC 1320b-14

§ 1320b–15. Protection of social security and medicare trust funds
(a) In general
No officer or employee of the United States shall—
(1) delay the deposit of any amount into (or delay the credit of any amount to) any Federal fund or otherwise vary from the normal terms, procedures, or timing for making such deposits or credits,
(2) refrain from the investment in public debt obligations of amounts in any Federal fund, or
(3) redeem prior to maturity amounts in any Federal fund which are invested in public debt obligations for any purpose other than the payment of benefits or administrative expenses from such Federal fund.
(b) “Public debt obligation” defined
(c) “Federal fund” defined
For purposes of this section, the term “Federal fund” means—
(1) the Federal Old-Age and Survivors Insurance Trust Fund;
(2) the Federal Disability Insurance Trust Fund;
(3) the Federal Hospital Insurance Trust Fund; and
(4) the Federal Supplementary Medical Insurance Trust Fund.
(Aug. 14, 1935, ch. 531, title XI, § 1145, as added Pub. L. 104–121, title I, § 107(a), Mar. 29, 1996, 110 Stat. 856.)

CITE AS: 42 USC 1320b-15

§ 1320b–16. Public disclosure of certain information on hospital financial interest and referral patterns
(Aug. 14, 1935, ch. 531, title XI, § 1146, as added Pub. L. 105–33, title IV, § 4321(c), Aug. 5, 1997, 111 Stat. 395.)

CITE AS: 42 USC 1320b-16

§ 1320b–17. Cross-program recovery of overpayments from benefits
(a) In general
(b) Limitation applicable to current benefits
(1) In generalIn carrying out subsection (a), the Commissioner of Social Security may not decrease the monthly amount payable to an individual under a program described in subsection (e) that is paid when regularly due—
(A) in the case of benefits under subchapter II or VIII, by more than 10 percent of the amount of the benefit payable to the person for that month under such subchapter; and
(B) in the case of benefits under subchapter XVI, by an amount greater than the lesser of—
(i) the amount of the benefit payable to the person for that month; or
(ii) an amount equal to 10 percent of the person’s income for that month (including such monthly benefit but excluding payments under subchapter II when recovery is also made from subchapter II payments and excluding income excluded pursuant to section 1382a(b) of this title).
(2) ExceptionParagraph (1) shall not apply if—
(A) the person or the spouse of the person was involved in willful misrepresentation or concealment of material information in connection with the amount incorrectly paid; or
(B) the person so requests.
(c) No effect on eligibility or benefit amount under subchapter VIII or XVIIn any case in which the Commissioner of Social Security takes action in accordance with subsection (a) to recover an amount incorrectly paid to any person, neither that person, nor (with respect to the program described in subsection (e)(3)) any individual whose eligibility for benefits under such program or whose amount of such benefits, is determined by considering any part of that person’s income, shall, as a result of such action—
(1) become eligible for benefits under the program described in paragraph (2) or (3) of subsection (e); or
(2) if such person or individual is otherwise so eligible, become eligible for increased benefits under such program.
(d) Inapplicability of prohibition against assessment and legal process
(e) Programs describedThe programs described in this subsection are the following:
(1) The old-age, survivors, and disability insurance benefits program under subchapter II.
(2) The special benefits for certain World War II veterans program under subchapter VIII.
(3) The supplemental security income benefits program under subchapter XVI (including, for purposes of this section, State supplementary payments paid by the Commissioner pursuant to an agreement under section 1382e(a) of this title or section 212(b) of Public Law 93–66).
(Aug. 14, 1935, ch. 531, title XI, § 1147, as added Pub. L. 105–306, § 8(a), Oct. 28, 1998, 112 Stat. 2928; amended Pub. L. 106–169, title II, § 251(b)(7), Dec. 14, 1999, 113 Stat. 1855; Pub. L. 108–203, title II, § 210(a), Mar. 2, 2004, 118 Stat. 516.)

CITE AS: 42 USC 1320b-17

§ 1320b–18. Repealed. Pub. L. 108–203, title II, § 210(b)(3), Mar. 2, 2004, 118 Stat. 517

CITE AS: 42 USC 1320b-18

§ 1320b–19. The Ticket to Work and Self-Sufficiency Program
(a) In general
(b) Ticket system
(1) Distribution of tickets
(2) Assignment of tickets
(3) Ticket terms
(4) Payments to employment networks
(c) State participation
(1) In general
(2) Effect of participation by State agency
(A) State agencies participating
(B) State agencies administering maternal and child health services programs
(3) Agreements between State agencies and employment networks
(d) Responsibilities of the Commissioner
(1) Selection and qualifications of program managers
(2) Tenure, renewal, and early terminationEach agreement entered into under paragraph (1) shall provide for early termination upon failure to meet performance standards which shall be specified in the agreement and which shall be weighted to take into account any performance in prior terms. Such performance standards shall include—
(A) measures for ease of access by beneficiaries to services; and
(B) measures for determining the extent to which failures in obtaining services for beneficiaries fall within acceptable parameters, as determined by the Commissioner.
(3) Preclusion from direct participation in delivery of services in own service areaAgreements under paragraph (1) shall preclude—
(A) direct participation by a program manager in the delivery of employment services, vocational rehabilitation services, or other support services to beneficiaries in the service area covered by the program manager’s agreement; and
(B) the holding by a program manager of a financial interest in an employment network or service provider which provides services in a geographic area covered under the program manager’s agreement.
(4) Selection of employment networks
(A) In general
(B) Alternate participants
(5) Termination of agreements with employment networks
(6) Quality assurance
(7) Dispute resolution
(e) Program managers
(1) In general
(2) Recruitment of employment networks
(3) Facilitation of access by beneficiaries to employment networks
(4) Ensuring availability of adequate services
(5) Reasonable access to services
(f) Employment networks
(1) Qualifications for employment networks
(A) In general
(B) One-stop delivery systems
(C) Compliance with selection criteria
(D) Single or associated providers allowed
(2) Requirements relating to provision of servicesEach employment network serving under the Program shall be required under the terms of its agreement with the Commissioner to—
(A) serve prescribed service areas; and
(B) take such measures as are necessary to ensure that employment services, vocational rehabilitation services, and other support services provided under the Program by, or under agreements entered into with, the employment network are provided under appropriate individual work plans that meet the requirements of subsection (g).
(3) Annual financial reporting
(4) Periodic outcomes reporting
(g) Individual work plans
(1) RequirementsEach employment network shall—
(A) take such measures as are necessary to ensure that employment services, vocational rehabilitation services, and other support services provided under the Program by, or under agreements entered into with, the employment network are provided under appropriate individual work plans that meet the requirements of subparagraph (C);
(B) develop and implement each such individual work plan, in partnership with each beneficiary receiving such services, in a manner that affords such beneficiary the opportunity to exercise informed choice in selecting an employment goal and specific services needed to achieve that employment goal;
(C) ensure that each individual work plan includes at least—
(i) a statement of the vocational goal developed with the beneficiary, including, as appropriate, goals for earnings and job advancement;
(ii) a statement of the services and supports that have been deemed necessary for the beneficiary to accomplish that goal;
(iii) a statement of any terms and conditions related to the provision of such services and supports; and
(iv) a statement of understanding regarding the beneficiary’s rights under the Program (such as the right to retrieve the ticket to work and self-sufficiency if the beneficiary is dissatisfied with the services being provided by the employment network) and remedies available to the individual, including information on the availability of advocacy services and assistance in resolving disputes through the State grant program authorized under section 1320b–21 of this title;
(D) provide a beneficiary the opportunity to amend the individual work plan if a change in circumstances necessitates a change in the plan; and
(E) make each beneficiary’s individual work plan available to the beneficiary in, as appropriate, an accessible format chosen by the beneficiary.
An individual work plan established pursuant to this subsection shall be treated, for purposes of section 51(d)(6)(B)(i) of the Internal Revenue Code of 1986, as an individualized written plan for employment under a State plan for vocational rehabilitation services approved under the Rehabilitation Act of 1973 [29 U.S.C. 701 et seq.].
(2) Effective upon written approval
(h) Employment network payment systems
(1) Election of payment system by employment networks
(A) In general
(B) No change in method of payment for beneficiaries with tickets already assigned to the employment networks
(2) Outcome payment system
(A) In general
(B) Payments made during outcome payment period
(C) Computation of payments to employment networkThe payment schedule of the outcome payment system shall be designed so that—
(i) the payment for each month during the outcome payment period for which benefits (described in paragraphs (3) and (4) of subsection (k)) are not payable is equal to a fixed percentage of the payment calculation base for the calendar year in which such month occurs; and
(ii) such fixed percentage is set at a percentage which does not exceed 40 percent.
(3) Outcome-milestone payment system
(A) In general
(B) Early payments upon attainment of milestones in advance of outcome payment periods
(C) Limitation on total payments to employment network
(4) DefinitionsIn this subsection:
(A) Payment calculation baseThe term “payment calculation base” means, for any calendar year—
(i) in connection with a title II disability beneficiary, the average disability insurance benefit payable under section 423 of this title for all beneficiaries for months during the preceding calendar year; and
(ii) in connection with a title XVI disability beneficiary (who is not concurrently a title II disability beneficiary), the average payment of supplemental security income benefits based on disability payable under subchapter XVI (excluding State supplementation) for months during the preceding calendar year to all beneficiaries who have attained 18 years of age but have not attained 65 years of age.
(B) Outcome payment periodThe term “outcome payment period” means, in connection with any individual who had assigned a ticket to work and self-sufficiency to an employment network under the Program, a period—
(i) beginning with the first month, ending after the date on which such ticket was assigned to the employment network, for which benefits (described in paragraphs (3) and (4) of subsection (k)) are not payable to such individual by reason of engagement in substantial gainful activity or by reason of earnings from work activity; and
(ii) ending with the 60th month (consecutive or otherwise), ending after such date, for which such benefits are not payable to such individual by reason of engagement in substantial gainful activity or by reason of earnings from work activity.
(5) Periodic review and alterations of prescribed schedules
(A) Percentages and periods
(B) Number and amounts of milestone payments
(C) Report on the adequacy of incentivesThe Commissioner shall submit to the Congress not later than 36 months after December 17, 1999, a report with recommendations for a method or methods to adjust payment rates under subparagraphs (A) and (B), that would ensure adequate incentives for the provision of services by employment networks of—
(i) individuals with a need for ongoing support and services;
(ii) individuals with a need for high-cost accommodations;
(iii) individuals who earn a subminimum wage; and
(iv) individuals who work and receive partial cash benefits.
The Commissioner shall consult with the Ticket to Work and Work Incentives Advisory Panel established under section 101(f) of the Ticket to Work and Work Incentives Improvement Act of 1999 during the development and evaluation of the study. The Commissioner shall implement the necessary adjusted payment rates prior to full implementation of the Ticket to Work and Self-Sufficiency Program.
(i) Suspension of disability reviews
(j) Authorizations
(1) Payments to employment networks
(A) Title II disability beneficiaries
(B) Title XVI disability beneficiaries
(2) Administrative expenses
(k) DefinitionsIn this section:
(1) Commissioner
(2) Disabled beneficiary
(3) Title II disability beneficiary
(4) Title XVI disability beneficiary
(5) Supplemental security income benefit
(l) Regulations
(Aug. 14, 1935, ch. 531, title XI, § 1148, as added Pub. L. 106–170, title I, § 101(a), Dec. 17, 1999, 113 Stat. 1863; amended Pub. L. 108–203, title IV, § 405(a), Mar. 2, 2004, 118 Stat. 526; Pub. L. 113–128, title V, § 512(dd)(2), July 22, 2014, 128 Stat. 1718.)

CITE AS: 42 USC 1320b-19

§ 1320b–20. Work incentives outreach program
(a) Establishment
(1) In general
(2) Grants, cooperative agreements, contracts, and outreachUnder the program established under this section, the Commissioner shall—
(A) establish a competitive program of grants, cooperative agreements, or contracts to provide benefits planning and assistance, including information on the availability of protection and advocacy services, to disabled beneficiaries, including individuals participating in the Ticket to Work and Self-Sufficiency Program established under section 1320b–19 of this title, the program established under section 1382h of this title, and other programs that are designed to encourage disabled beneficiaries to work;
(B) conduct directly, or through grants, cooperative agreements, or contracts, ongoing outreach efforts to disabled beneficiaries (and to the families of such beneficiaries) who are potentially eligible to participate in Federal or State work incentive programs that are designed to assist disabled beneficiaries to work, including—
(i) preparing and disseminating information explaining such programs; and
(ii) working in cooperation with other Federal, State, and private agencies and nonprofit organizations that serve disabled beneficiaries, and with agencies and organizations that focus on vocational rehabilitation and work-related training and counseling;
(C) establish a corps of trained, accessible, and responsive work incentives specialists within the Social Security Administration who will specialize in disability work incentives under subchapters II and XVI for the purpose of disseminating accurate information with respect to inquiries and issues relating to work incentives to—
(i) disabled beneficiaries;
(ii) benefit applicants under subchapters II and XVI; and
(iii) individuals or entities awarded grants under subparagraphs 1
1 So in original. Probably should be “subparagraph”.
(A) or (B); and
(D) provide—
(i) training for work incentives specialists and individuals providing planning assistance described in subparagraph (C); and
(ii) technical assistance to organizations and entities that are designed to encourage disabled beneficiaries to return to work.
(3) Coordination with other programs
(b) Conditions
(1) Selection of entities
(A) Application
(B) Statewideness
(C) Eligibility of States and private organizations
(i) In general
(ii) Agencies and entities describedThe agencies and entities described in this clause are the following:(I) Any public or private agency or organization (including Centers for Independent Living established under title VII of the Rehabilitation Act of 1973 (29 U.S.C. 796 et seq.), protection and advocacy organizations, client assistance programs established in accordance with section 112 of the Rehabilitation Act of 1973 (29 U.S.C. 732), and State Developmental Disabilities Councils established in accordance with section 6024 2
2 See References in Text note below.
of this title) that the Commissioner determines satisfies the requirements of this section.(II) The State agency administering the State program funded under part A of subchapter IV.
(D) Exclusion for conflict of interest
(2) Services providedA recipient of a grant, cooperative agreement, or contract to provide benefits planning and assistance shall select individuals who will act as planners and provide information, guidance, and planning to disabled beneficiaries on the—
(A) availability and interrelation of any Federal or State work incentives programs designed to assist disabled beneficiaries that the individual may be eligible to participate in;
(B) adequacy of any health benefits coverage that may be offered by an employer of the individual and the extent to which other health benefits coverage may be available to the individual; and
(C) availability of protection and advocacy services for disabled beneficiaries and how to access such services.
(3) Amount of grants, cooperative agreements, or contracts
(A) Based on population of disabled beneficiaries
(B) Limitations
(i) Per grant
(ii) Total amount for all grants, cooperative agreements, and contracts
(4) Funding
(A) Allocation of costs
(B) Carryover
(c) Annual report
(d) DefinitionsIn this section:
(1) Commissioner
(2) Disabled beneficiaryThe term “disabled beneficiary” means an individual—
(A) who is a disabled beneficiary as defined in section 1320b–19(k)(2) of this title;
(B) who is receiving a cash payment described in section 1382e(a) of this title or a supplementary payment described in section 212(a)(3) of Public Law 93–66 (without regard to whether such payment is paid by the Commissioner pursuant to an agreement under section 1382e(a) of this title or under section 212(b) of Public Law 93–66);
(C) who, pursuant to section 1382h(b) of this title, is considered to be receiving benefits under subchapter XVI of this chapter; or
(D) who is entitled to benefits under part A of subchapter XVIII of this chapter by reason of the penultimate sentence of section 426(b) of this title.
(e) Authorization of appropriations
(Aug. 14, 1935, ch. 531, title XI, § 1149, as added Pub. L. 106–170, title I, § 121, Dec. 17, 1999, 113 Stat. 1887; amended Pub. L. 108–203, title IV, §§ 404(a)(1), 407(a), Mar. 2, 2004, 118 Stat. 525, 527; Pub. L. 111–63, § 2, Sept. 18, 2009, 123 Stat. 2001; Pub. L. 111–280, §§ 2(a), 3(a), (b)(1), Oct. 13, 2010, 124 Stat. 2903; Pub. L. 113–128, title V, § 512(dd)(3), July 22, 2014, 128 Stat. 1718.)

CITE AS: 42 USC 1320b-20

§ 1320b–21. State grants for work incentives assistance to disabled beneficiaries
(a) In general
(b) Services providedServices provided to disabled beneficiaries pursuant to a payment made under this section may include—
(1) information and advice about obtaining vocational rehabilitation and employment services; and
(2) advocacy or other services that a disabled beneficiary may need to secure, maintain, or regain gainful employment.
(c) Application
(d) Amount of payments
(1) In generalSubject to the amount appropriated for a fiscal year for making payments under this section, a protection and advocacy system shall not be paid an amount that is less than—
(A) in the case of a protection and advocacy system located in a State (including the District of Columbia and Puerto Rico) other than Guam, American Samoa, the United States Virgin Islands, and the Commonwealth of the Northern Mariana Islands, the greater of—
(i) $100,000; or
(ii) ⅓ of 1 percent of the amount available for payments under this section; and
(B) in the case of a protection and advocacy system located in Guam, American Samoa, the United States Virgin Islands, and the Commonwealth of the Northern Mariana Islands, $50,000.
(2) Inflation adjustment
(e) Annual report
(f) Funding
(1) Allocation of payments
(2) Carryover
(g) DefinitionsIn this section:
(1) Commissioner
(2) Disabled beneficiaryThe term “disabled beneficiary” means an individual—
(A) who is a disabled beneficiary as defined in section 1320b–19(k)(2) of this title;
(B) who is receiving a cash payment described in section 1382e(a) of this title or a supplementary payment described in section 212(a)(3) of Public Law 93–66 (without regard to whether such payment is paid by the Commissioner pursuant to an agreement under section 1382e(a) of this title or under section 212(b) of Public Law 93–66);
(C) who, pursuant to section 1382h(b) of this title, is considered to be receiving benefits under subchapter XVI of this chapter; or
(D) who is entitled to benefits under part A of subchapter XVIII of this chapter by reason of the penultimate sentence of section 426(b) of this title.
(3) Protection and advocacy system
(h) Authorization of appropriations
(Aug. 14, 1935, ch. 531, title XI, § 1150, as added Pub. L. 106–170, title I, § 122, Dec. 17, 1999, 113 Stat. 1890; amended Pub. L. 108–203, title IV, §§ 404(b)(1), (2), 407(b), Mar. 2, 2004, 118 Stat. 526, 527; Pub. L. 111–63, § 3, Sept. 18, 2009, 123 Stat. 2001; Pub. L. 111–280, § 2(b), Oct. 13, 2010, 124 Stat. 2903.)

CITE AS: 42 USC 1320b-21

§ 1320b–22. Grants to develop and establish State infrastructures to support working individuals with disabilities
(a) Establishment
(1) In general
(2) Application
(3) Definition of State
(b) Grants for infrastructure and outreach
(1) In general
Out of the funds appropriated under subsection (e), the Secretary shall award grants to States to—
(A) support the establishment, implementation, and operation of the State infrastructures described in subsection (a); and
(B) conduct outreach campaigns regarding the existence of such infrastructures.
(2) Eligibility for grants
(A) In general
(B) Definitions
In this section:
(i) Employed
The term “employed” means—
(I) earning at least the applicable minimum wage requirement under section 206 of title 29 and working at least 40 hours per month; or(II) being engaged in a work effort that meets substantial and reasonable threshold criteria for hours of work, wages, or other measures, as defined and approved by the Secretary.
(ii) Personal assistance services
(3) Determination of awards
(A) In general
Subject to subparagraph (B), the Secretary shall develop a methodology for awarding grants to States under this section for a fiscal year in a manner that—
(i) rewards States for their efforts in encouraging individuals described in paragraph (2)(A) to be employed; and
(ii) does not provide a State that has not elected to provide medical assistance under subchapter XIX of this chapter to individuals described in section 1396a(a)(10)(A)(ii)(XIII) of this title with proportionally more funds for a fiscal year than a State that has exercised such election.
(B) Award limits
(i) Minimum awards(I) In general(II) Pro rata reductions
(ii) Maximum awards(I) States that elected optional medicaid eligibility(II) Other States
(c) Availability of funds
(1) Funds awarded to States
(2) Funds not awarded to States
(d) Annual report
(e) Appropriation
(1) In general
Out of any funds in the Treasury not otherwise appropriated, there is appropriated to make grants under this section—
(A) for fiscal year 2001, $20,000,000;
(B) for fiscal year 2002, $25,000,000;
(C) for fiscal year 2003, $30,000,000;
(D) for fiscal year 2004, $35,000,000;
(E) for fiscal year 2005, $40,000,000; and
(F) for each of fiscal years 2006 through 2011, the amount appropriated for the preceding fiscal year increased by the percentage increase (if any) in the Consumer Price Index for All Urban Consumers (United States city average) for the preceding fiscal year.
(2) Budget authority
(f) Recommendation
(Pub. L. 106–170, title II, § 203, Dec. 17, 1999, 113 Stat. 1894.)

CITE AS: 42 USC 1320b-22

§ 1320b–23. Pharmacy benefit managers transparency requirements
(a) Provision of information
A health benefits plan or any entity that provides pharmacy benefits management services on behalf of a health benefits plan (in this section referred to as a “PBM”) that manages prescription drug coverage under a contract with—
(1) a PDP sponsor of a prescription drug plan or an MA organization offering an MA–PD plan under part D of subchapter XVIII; or
(2) a qualified health benefits plan offered through an exchange established by a State under section 18031 of this title,
shall provide the information described in subsection (b) to the Secretary and, in the case of a PBM, to the plan with which the PBM is under contract with, at such times, and in such form and manner, as the Secretary shall specify.
(b) Information described
The information described in this subsection is the following with respect to services provided by a health benefits plan or PBM for a contract year:
(1) The percentage of all prescriptions that were provided through retail pharmacies compared to mail order pharmacies, and the percentage of prescriptions for which a generic drug was available and dispensed (generic dispensing rate), by pharmacy type (which includes an independent pharmacy, chain pharmacy, supermarket pharmacy, or mass merchandiser pharmacy that is licensed as a pharmacy by the State and that dispenses medication to the general public), that is paid by the health benefits plan or PBM under the contract.
(2) The aggregate amount, and the type of rebates, discounts, or price concessions (excluding bona fide service fees, which include but are not limited to distribution service fees, inventory management fees, product stocking allowances, and fees associated with administrative services agreements and patient care programs (such as medication compliance programs and patient education programs)) that the PBM negotiates that are attributable to patient utilization under the plan, and the aggregate amount of the rebates, discounts, or price concessions that are passed through to the plan sponsor, and the total number of prescriptions that were dispensed.
(3) The aggregate amount of the difference between the amount the health benefits plan pays the PBM and the amount that the PBM pays retail pharmacies, and mail order pharmacies, and the total number of prescriptions that were dispensed.
(c) Confidentiality
Information disclosed by a health benefits plan or PBM under this section is confidential and shall not be disclosed by the Secretary or by a plan receiving the information, except that the Secretary may disclose the information in a form which does not disclose the identity of a specific PBM, plan, or prices charged for drugs, for the following purposes:
(1) As the Secretary determines to be necessary to carry out this section or part D of subchapter XVIII.
(2) To permit the Comptroller General to review the information provided.
(3) To permit the Director of the Congressional Budget Office to review the information provided.
(4) To States to carry out section 18031 of this title.
(d) Penalties
(Aug. 14, 1935, ch. 531, title XI, § 1150A, as added Pub. L. 111–148, title VI, § 6005, Mar. 23, 2010, 124 Stat. 698.)

CITE AS: 42 USC 1320b-23

§ 1320b–24. Consultation with Tribal Technical Advisory Group

The Secretary of Health and Human Services shall maintain within the Centers for Medicaid & Medicare Services 1

1 So in original. Probably should be “Centers for Medicare & Medicaid Services”.
(CMS) a Tribal Technical Advisory Group (TTAG), which was first established in accordance with requirements of the charter dated September 30, 2003, and the Secretary of Health and Human Services shall include in such Group a representative of a national urban Indian health organization and a representative of the Indian Health Service. The inclusion of a representative of a national urban Indian health organization in such Group shall not affect the nonapplication of chapter 10 of title 5 to such Group.

(Pub. L. 111–5, div. B, title V, § 5006(e)(1), Feb. 17, 2009, 123 Stat. 510; Pub. L. 117–286, § 4(a)(250), Dec. 27, 2022, 136 Stat. 4333.)

CITE AS: 42 USC 1320b-24

§ 1320b–25. Reporting to law enforcement of crimes occurring in federally funded long-term care facilities
(a) Determination and notification
(1) Determination
(2) Notification
(3) Covered individual defined
(b) Reporting requirements
(1) In general
(2) Timing
If the events that cause the suspicion—
(A) result in serious bodily injury, the individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; and
(B) do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion.
(c) Penalties
(1) In general
If a covered individual violates subsection (b)—
(A) the covered individual shall be subject to a civil money penalty of not more than $200,000; and
(B) the Secretary may make a determination in the same proceeding to exclude the covered individual from participation in any Federal health care program (as defined in section 1320a–7b(f) of this title).
(2) Increased harm
If a covered individual violates subsection (b) and the violation exacerbates the harm to the victim of the crime or results in harm to another individual—
(A) the covered individual shall be subject to a civil money penalty of not more than $300,000; and
(B) the Secretary may make a determination in the same proceeding to exclude the covered individual from participation in any Federal health care program (as defined in section 1320a–7b(f) of this title).
(3) Excluded individual
(4) Extenuating circumstances
(A) In general
(B) Underserved population defined
In this paragraph, the term “underserved population” means the population of an area designated by the Secretary as an area with a shortage of elder justice programs or a population group designated by the Secretary as having a shortage of such programs. Such areas or groups designated by the Secretary may include—
(i) areas or groups that are geographically isolated (such as isolated in a rural area);
(ii) racial and ethnic minority populations; and
(iii) populations underserved because of special needs (such as language barriers, disabilities, alien status, or age).
(d) Additional penalties for retaliation
(1) In general
A long-term care facility may not—
(A) discharge, demote, suspend, threaten, harass, or deny a promotion or other employment-related benefit to an employee, or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done by the employee; or
(B) file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee,
for making a report, causing a report to be made, or for taking steps in furtherance of making a report pursuant to subsection (b)(1).
(2) Penalties for retaliation
(3) Requirement to post notice
(e) Procedure
(f) Definitions
(Aug. 14, 1935, ch. 531, title XI, § 1150B, as added Pub. L. 111–148, title VI, § 6703(b)(3), Mar. 23, 2010, 124 Stat. 800.)

CITE AS: 42 USC 1320b-25

§ 1320b–26. Funding for providers relating to COVID–19
(a) Funding
(b) Application requirementTo be eligible for a payment under this section, an eligible health care provider shall submit to the Secretary an application in such form and manner as the Secretary shall prescribe. Such application shall contain the following:
(1) A statement justifying the need of the provider for the payment, including documentation of the health care related expenses attributable to COVID–19 and lost revenues attributable to COVID–19.
(2) The tax identification number of the provider.
(3) Such assurances as the Secretary determines appropriate that the eligible health care provider will maintain and make available such documentation and submit such reports (at such time, in such form, and containing such information as the Secretary shall prescribe) as the Secretary determines is necessary to ensure compliance with any conditions imposed by the Secretary under this section.
(4) Any other information determined appropriate by the Secretary.
(c) LimitationPayments made to an eligible health care provider under this section may not be used to reimburse any expense or loss that—
(1) has been reimbursed from another source; or
(2) another source is obligated to reimburse.
(d) Application of requirements, rules, and procedures
(e) DefinitionsIn this section:
(1) Eligible health care providerThe term “eligible health care provider” means—
(A) a provider of services (as defined in section 1395x(u) of this title) or a supplier (as defined in section 1395x(d) of this title) that—
(i) is enrolled in the Medicare program under subchapter XVIII under section 1395cc(j) of this title (including temporarily enrolled during the emergency period described in section 1320b–5(g)(1)(B) of this title for such period);
(ii) provides diagnoses, testing, or care for individuals with possible or actual cases of COVID–19; and
(iii) is a rural provider or supplier; or
(B) a provider or supplier that—
(i) is enrolled with a State Medicaid plan under subchapter XIX (or a waiver of such plan) in accordance with subsections (a)(77) and (kk) of section 1396a of this title (including enrolled pursuant to section 1396a(a)(78) or section 1396u–2(d)(6) of this title) or enrolled with a State child health plan under subchapter XXI (or a waiver of such plan) in accordance with subparagraph (G) of section 1397gg(e)(1) of this title (including enrolled pursuant to subparagraph (D) or (Q) of such section);
(ii) provides diagnoses, testing, or care for individuals with possible or actual cases of COVID–19; and
(iii) is a rural provider or supplier.
(2) Health care related expenses attributable to COVID–19
(3) Lost revenue attributable to COVID–19
(4) Payment
(5) Rural provider or supplierThe term “rural provider or supplier” means—
(A) a—
(i) provider or supplier located in a rural area (as defined in section 1395ww(d)(2)(D) of this title); or
(ii) provider treated as located in a rural area pursuant to section 1395ww(d)(8)(E) of this title;
(B) a provider or supplier located in any other area that serves rural patients (as defined by the Secretary), which may include, but is not required to include, a metropolitan statistical area with a population of less than 500,000 (determined based on the most recently available data);
(C) a rural health clinic (as defined in section 1395x(aa)(2) of this title);
(D) a provider or supplier that furnishes home health, hospice, or long-term services and supports in an individual’s home located in a rural area (as defined in section 1395ww(d)(2)(D) of this title); or
(E) any other rural provider or supplier (as defined by the Secretary).
(Aug. 14, 1935, ch. 531, title XI, § 1150C, as added Pub. L. 117–2, title IX, § 9911, Mar. 11, 2021, 135 Stat. 236.)

CITE AS: 42 USC 1320b-26